The nonoperative management of fistula-in-ano

A case-control study of the risk factors for fistula-in-ano in infants and toddlers

BACKGROUND

Limited data are available regarding the risk factors for fistula-in-ano (FIA) in infants and toddlers, potentially affecting their daily lives.

OBJECTIVES

The purpose of this study was to identify potential risk factors for FIA in infants and toddlers, in order to implement early preventive interventions, avoid disease progression, and develop therapeutic strategies.

DESIGN AND SETTINGS

A retrospective case-control study was conducted, comparing 41 infants and toddlers diagnosed with FIA with 41 healthy controls, between August 2020 and December 2021.

INDEPENDENT VARIABLES

(a) maternal characteristics during pregnancy and delivery, (b) perinatal characteristics, dietary behaviors, and defecation-related behaviors in infants and toddlers, (c) family dietary behaviors.

RESULTS

Mothers of infants and toddlers with FIA had given birth more times in the past, while the infants and toddlers themselves had less mealtime, a higher rate of exclusive breastfeeding, frequent loose stools, and a larger proportion of used wipes, experiencing perianal skin anomalies. The logistic regression analysis revealed that there are four significant risk factors associated with the development of FIA in infants and toddlers, including the number of previous deliveries by the mother (OR 6.327), defecation frequency score (OR 5.351), stool consistency score (OR 5.017), and cleaning with wipes after defecation (OR 8.089).

CONCLUSION

Based on our data, it appeared that FIA in infants and toddlers could be attributed to several factors. These included an increased number of previous deliveries by mothers, frequent loose stools, and repeated wipe use. To prevent the occurrence and worsening of the disease, it is important to improve the frequency and consistency of stooling and provide proper care. Further research is required to verify these findings in other clinical settings.

James Warden and the Global Alliance Partnership: A Pediatric Surgery Giant and His Enduring PAPS Landmark

The discipline of pediatric surgery has honored many of the early giants through programs that bear their names. One of those programs is the M. James Warden Global Alliance Partnership, a landmark program celebrated at each annual meeting of the Pacific Association of Pediatric Surgeons since 1989. This article describes James Warden and his legacy as a surgeon and humanitarian and provides an update on the past, present, and future of the Global Alliance Partnership that bears his name. LEVEL OF EVIDENCE: 5.

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

Background

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

Methods

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

Results

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

Conclusions

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

Natural course of perianal abscess in infants: a real-world study

Natural course of perianal abscess (PA) in infancy remains obscure. This study aimed to investigate the natural course of infants with PA after conservative treatment. A retrospective cohort study was conducted in infants with PA who were treated conservatively (due to the parents' refusal of surgery), for more than 2 months between 2014 and 2020 at a single tertiary center. 153 patients (149 boys and 4 girls) were identified. The median follow-up was 5.3 years (range 3-8.2 years). Initially, 119 patients (77.8%) were completely cured by conservative treatment, and 34 (22.2%) failed. Among the 34 patients, 23 continued conservative treatment (20 cure, 3 fistula formation) and 11 underwent surgery. After conservative treatment, the rate of fistula formation, abscess recurrence, and new-onset abscess were 15.0%, 4.6%, and 6.5%, respectively. Overall, 139 patients (90.8%) were cured conservatively without surgery, and 11 (7.2%) underwent surgical management. In addition, 3 (2.0%) patients developed fistula-in-ano (under observation). PA in infants may be a time-limited and self-limited condition. Conservative management should be the first choice of treatment in most cases. Longer periods of conservative treatment may achieve better clinical outcomes in selected cases. There will be a percentage of patients (about 10%) that would require surgical treatment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

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

Treatment of pediatric fistula-in-ano-Sphincter-sparing non-cutting seton placement as the future treatment of choice?

Background

Therapeutic principles of fistula-in-ano (FIA) are lacking evidence-based consensus on treatment options. Non-cutting, sphincter-sparing options have not been published for infancy and childhood FIA.

Patients and methods

We are presenting retrospective data on FIA treatment with non-cutting seton placement between 2011 and 2020. Data were collected based on medical records and complemented by patients' contact for follow-up analyses between November 2021 and October 2022. Data were analyzed regarding the outcome variables of recurrent FIA and recurrent perianal abscess. Furthermore, outcomes in different age groups were compared (<1/1.5-12 years of age).

Results

Treatment duration with non-cutting seton was at a median of 4.6 months and was not associated with recurrent FIA (p = 0.8893). Overall recurrence rate of FIA within an observation time of 9 months postsurgically was at 7% (n = 3/42) and was only seen in infancy, whereas recurrent perianal abscess was mainly observable in children (n = 2, p = 0.2132). Comparison of age groups revealed no significant differences. Of the 42 included patients, 37 responded in the follow-up analysis, resulting in a response rate of 88% with a median follow-up time of 4.9 years. Fecal incontinence was postsurgically only seen in two patients, who were diagnosed prior to surgery and symptoms remained unchanged.

Conclusions

Non-cutting seton placement might be a promising option in the treatment of FIA in infancy and childhood. Perioperative settings like duration of placed seton and antibiotic treatment have to be discussed in further prospective, enlarged population-based studies.

Can transcutaneous perianal ultrasonography be the first-line diagnostic instrument for evaluating pediatric perianal fistulas?

BACKGROUND

Pediatric perianal fistula is a common disorder. It is more difficult to detect the fistula tract and internal opening (IO) in children than in adults. This study aimed to evaluate the clinical diagnostic value of transcutaneous perianal ultrasound for children with perianal fistula.

METHODS

A retrospective review was conducted by analysing the preoperative transcutaneous perianal ultrasound and intraoperative exploration results of 203 consecutive patients who were <3 years old and diagnosed with perianal fistula. Analyses were conducted to evaluate the accuracy and consistency of utilizing the transcutaneous perianal ultrasound in the diagnosis of the complexity and location of the IO of perianal fistulas.

RESULTS

Compared with intraoperative exploration, the preoperative transcutaneous perianal ultrasonography has almost perfect agreement (Kappa = 0.881, P < 0.001) in the diagnosis of fistula tract complexity and IO with a sensitivity of 92% and a specificity of 97%. In addition, both intraoperative exploration and transcutaneous perianal ultrasound diagnosis showed high consistency in the identification of the IO of perianal fistulas (Quadrant I Kappa = 0.831, Quadrant II Kappa = 0.773, Quadrant III Kappa = 0.735, Quadrant IV Kappa = 0.802, all P < 0.01). The IOs were mainly distributed in Quadrants IV and II in both simple and complex fistulas.

CONCLUSIONS

Transcutaneous perianal ultrasound, as a non-invasive and simple imaging technique, showed high accuracy in the diagnosis and identification of the fistula classification and IO location. It could be considered a first-line diagnostic instrument for evaluating perianal fistulas among children.

Treatment of perianal abscess in children: spontaneous drainage or incision-drainage?

Background

The aim of the study is to evaluate the clinical characteristics and compare the treatment methods for perianal abscesses by assessing our treatment experiences.

Methods

We have retrospectively analyzed the records of the children who received perianal abscess and fistula-in-ano treatment between January 2014 and January 2022. Demographic information of the patients, complaints, treatment procedures, abscess recurrence, and development of fistula-in-ano was evaluated. Patients with systemic diseases and inflammatory bowel diseases were excluded from the study.

Results

A total of 312 children (230 boys, 82 girls) were included in the study. The median age was 24.3 ± 18.1 months (1–216). In the first examination, 61 (19.5%) patients had fistula-in-ano and 25 1(80.5%) patients had a perianal abscess. The most common symptoms were erythema in the perianal region, mass, constipation, rectal bleeding, and inability to defecate. Spontaneous drainage was determined in 34.3% (n = 86) of the perianal abscess, and 65.7% (n = 165) of perianal abscesses were treated with incision-drainage without general anesthesia and systemic antibiotherapy. In the follow-up, fistula-in-ano formed in 27 patients who had a perianal abscess. Twenty-four of the patients who developed fistula-in-ano, were seen after spontaneous drainage, and 3 of them were seen after incision drainage. Perianal abscess recurred in 64 patients. Spontaneously drained abscess significantly increased the development of fistula-in-ano (p = 0.001). However, recurrences in a perianal abscess (25.4%) do not increase the fistula-in-ano formation (p > 0.05). In fistula-in-ano treatment, 10 (11.5%) patients were resolved spontaneously, 70 (79.5%) patients were treated with fistulotomy and 8 (9%) patients were treated with fistulectomy.

Conclusion

Treatment of perianal abscess and fistula-in-ano in children is still controversial. According to our results, incision-drainage and antibiotic usage in the treatment of the perianal abscess are the most appropriate treatment to decrease the rate of fistula-in-ano.

Intermediate-Term Evaluation of Initial Non-Surgical Management of Pediatric Perianal Abscess and Fistula-In-Ano

Background: Non-surgical intervention has been proposed for the management of perianal abscess (PA) and fistula-in-ano (FIA), with potential benefits in terms of quality of life, wound healing, and functional outcome, although this strategy remains rare and controversial. Here, we aimed to compare the intermediate-term outcomes of non-surgical management with those of surgical incision and/or drainage. Patients and Methods: A study of pediatric patients with first-time PA and/or FIA was conducted retrospectively from January 2010 to December 2020. The patient population was stratified by surgical and non-surgical management. The clinical outcomes, including PA recurrence, FIA formation, and wound healing time, were compared between the surgical and non-surgical management groups. Results: A total of 457 patients managed for first-time PA and/or FIA were eligible for the current study. Of these patients, 169 (50.9%) patients received non-surgical intervention. There were no differences in terms of age, gender distribution, wound healing course, or abscess size between the two groups. Furthermore, no difference was noted between the two groups in terms of PA recurrence and/or FIA development rates and revisits for additional treatment. Conclusions: Although PA/FIA management is still controversial, non-surgical intervention exhibited promising outcomes for most cases of first-time PA/FIA, with fewer hospital admissions and surgical procedures and similar recurrence and fistula formation incidences. Immediate surgical intervention might be avoided because PA/FIA has a chance for spontaneous resolution in children.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Management of perianal abscesses in infants without general anaesthesia: a systematic review of the literature

Perianal abscesses are a common surgical presentation in infants. Historically, general anaesthesia (GA) has been used to facilitate incision and drainage, with or without exploration for a fistula-in-ano (FIA). This review aims to assess outcomes following management of perianal abscesses without GA in infants less than 24 months old. We aim to identify the success of management without GA. Using PRISMA guidelines, studies were identified from MEDLINE, EMBASE and PubMed. Studies including infants less than 24 months with perianal abscesses managed without GA were reviewed. The primary outcome was the number of patients requiring GA following initial management without GA. Secondary outcomes included rates of recurrent perianal abscesses, rates of progression to FIA and time to cure. Nine studies, involving 1049 infants less than 24 months old met inclusion criteria. A total of 1039 (99.0%) were males. Study design consisted of one prospective case series of 18 patients, and eight retrospective cohort studies. There were no randomized control trials. A total of 1037 (98.9%) patients were initially managed without GA. Of these, 59 (5.6%) were documented to subsequently require a general anaesthetic. Treatment modalities included antibiotics, regular baths, needle aspiration, incision and drainage under local anaesthesia, hainosankyuto and fibroblast growth factor. A total of 790 (75.3%) healed primarily without further intervention. A total of 243 (23.2%) were documented to have a recurrence or progression to FIA. All patients who required a subsequent general anaesthetic had progressed to FIA. Despite the lack of well-designed prospective studies, existing evidence supports management of perianal abscesses without initial GA in infants, with more than 75% healing completely. Further research aimed at standardizing care and confirming the safety and efficacy of initial non-operative management are warranted, and may potentially reduce the number of unnecessary initial and subsequent clinical interventions.

Perianal Abscesses and Fistulas in Infants and Children

Perianal abscess (PA) and fistula-in-ano (FIA) are common entities in infancy. Although several hypotheses have been suggested, the pathogenesis of PA/FIA remains elusive. The natural course of these diseases in infancy is self-limiting in the majority of cases whereas older children show similarities to PA/FIA in adults. It is important to rule out rare differential diagnoses of PA/FIA such as inflammatory bowel disease (IBD), surgical complications after colorectal surgery, and immunodeficiencies. Treatment remains empiric, comprises conservative, as well as surgical approaches, and is dependent on the age of the patient. This review summarizes anatomical aspects, current evidence on disease pathogenesis, clinical presentation, and management of pediatric patients with PA and FIA.

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

BACKGROUND

The optimal management of perianal abscess in children is controversial.

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Perineal canal repair using modified Tsuchida’s technique

Background

The perineal canal is a rare variety of anorectal malformations, identified by different nomenclatures like H fistula, double termination of the alimentary canal, and anovestibular fistula. Various approaches to repair this anomaly have been proposed.

The present study aimed to review the results of perineal canal repair with modified Tsuchida’s technique, in seven girls treated in our unit between 2014 and 2019. These were classified as acquired and congenital type of perineal canal, depending upon their clinical presentations.

Results

Of the total seven cases, it was found that three of them had a perineal abscess and persistent anovestibular fistula formation, and they underwent definitive repair of the perineal canal after 12 weeks as they did not respond to the conservative management. Four girls had congenital anovestibular fistula without infection. All the patients underwent covering colostomy and definitive repair by modified Tsuchida’s technique. One patient had a recurrence of the fistula, due to early closure of colostomy and underwent redo repair. One patient with known immune deficiency died before colostomy closure due to severe sepsis. During the last follow-up, all six girls were continent (Kelly’s score 6/6), and the perineum had healed well.

Conclusion

The perineal canal can be acquired or congenital. Irrespective of its etiology, modified Tsuchida’s technique has been found to be an easy and satisfactory method of its repair.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Combination therapy with traditional medicines for perianal abscess in children

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Variation in Antibiotic Selection and Clinical Outcomes in Infants <60 Days Hospitalized With Skin and Soft Tissue Infections

OBJECTIVES

To describe variation in empirical antibiotic selection in infants <60 days old who are hospitalized with skin and soft-tissue infections (SSTIs) and to determine associations with outcomes, including length of stay (LOS), 30-day returns (emergency department revisit or readmission), and standardized cost.

METHODS

Using the Pediatric Health Information System, we conducted a retrospective study of infants hospitalized with SSTI from 2009 to 2014. We analyzed empirical antibiotic selection in the first 2 days of hospitalization and categorized antibiotics as those typically administered for (1) staphylococcal infection, (2) neonatal sepsis, or (3) combination therapy (staphylococcal infection and neonatal sepsis). We examined the association of antibiotic selection and outcomes using generalized linear mixed-effects models.

RESULTS

A total of 1319 infants across 36 hospitals were included; the median age was 30 days (interquartile range [IQR]: 17-42 days). We observed substantial variation in empirical antibiotic choice, with 134 unique combinations observed before categorization. The most frequently used antibiotics included staphylococcal therapy (50.0% [IQR: 39.2-58.1]) and combination therapy (45.4% [IQR: 36.0-56.0]). Returns occurred in 9.2% of infants. Compared with administration of staphylococcal antibiotics, use of combination therapy was associated with increased LOS (adjusted rate ratio: 1.35; 95% confidence interval: 1.17-1.53) and cost (adjusted rate ratio: 1.39; 95% confidence interval: 1.21-1.58), but not with 30-day returns.

CONCLUSIONS

Infants who are hospitalized with SSTI experience wide variation in empirical antibiotic selection. Combination therapy was associated with increased LOS and cost, with no difference in returns. Our findings reveal the need to identify treatment strategies that can be used to optimize resource use for infants with SSTI.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A systematic review of the management of anal fistula in infants

BACKGROUND

Fistula-in-ano (FIA) in infants differs, in several ways, from FIA in adults. The current review aims to assess FIA in infants less than 2 years old and to illustrate the outcome of different treatment modalities described in the literature.

METHODS

An organized search of the English literature over the past 25 years was conducted according to the preferred reporting items for systematic reviews and meta-analyses guidelines. Electronic databases and Google Scholar were searched for articles focusing on management of FIA in infants.

RESULTS

Fourteen studies were eligible for this review. Variables analyzed comprised patient characteristics, type of FIA, methods of treatment, recurrence, and postoperative complications. The studies included comprised total of 490 infants, 89 % of them less than 1 year old. Most patients (97.5 %) were males with a median age of 7 months. Around 20 % of patients with FIA underwent conservative treatment initially, and 73 % of them achieved complete resolution. Surgery was performed on 86 % of the infants. Fistulotomy accounted for 65 % of the procedures performed and was associated with a higher recurrence rate than fistulectomy (6.6 vs. 1.1 %, respectively). Complications of surgical management occurred in 2.6 % of the patients. FIA typically occurs in male infants, mainly under 1 year of age. Almost all fistulae in this age group are low.

CONCLUSIONS

The majority of the studies reviewed evaluated surgical treatment of FIA. However, the few studies that employed conservative treatment reported complete resolution of FIA in most infants. Fistulotomy was the most commonly performed surgery for FIA and was associated with fewer complications, yet a higher recurrence rate than fistulectomy.

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

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

Infantile Fistula-in-Ano: A Report of Two Patients and Review for Dermatologists

Infantile fistula-in-ano is a well-known entity to pediatric surgeons but less recognized by dermatologists. Because these patients may initially present to a dermatologist or pediatric dermatologist, familiarity with the presentation is important. We present two infants with fistula-in-ano and review the literature on this condition.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Repair of fistulae in-ano in children using image guided Histoacryl injection after failure of conservative treatment

PURPOSE

Our aim is to determine the feasibility and safety of N Butyl Cyanoacrylate (HISTOACRYL), adhesive material in the treatment of fistula in-ano in infants and children.

PATIENTS AND METHODS

30 patients who presented with a perianal fistula (25 males and 5 females) were studied. Their ages ranged from 9 months to 15 years. All patients received medical (conservative) treatment. Six patients improved, 7 patients were subjected to surgical intervention, and the remaining 17 patients were managed by injection of adhesive material through the fistula under fluoroscopic guidance and general anesthesia after failure of medical management.

RESULTS

Of the 17 children who underwent injection therapy to the fistula in-ano after failed medical management, 14 patients were males. The procedure time was 10 to 15 min. The mean follow up was 18 months. Two patients had a recurrence after one to two months. They were subjected to reinjection, and one of them had a second recurrence. Overall, 16 (94%) of 17 patients have had successful closure of their fistula, and one of them healed from a second injection.

CONCLUSION

Our method of tissue adhesive Cyanoacrylate injection is safe, feasible, and can be used repeatedly in treatment of fistula in-ano in infants and children.

Perianal abscess in children: aiming for optimal management

BACKGROUND

Perianal abscess is common in infants and children, yet the optimal surgical management is argued: incision and drainage alone is a simple procedure but is associated with a much higher recurrence rate than incision and drainage with simultaneous laying open of the associated fistula. This retrospective review established the institutional recurrence rate and its close association with how the fistula was managed at the initial operation.

METHODS

A retrospective review of all children requiring an operation for a perianal abscess over a 13-year period from 1996 to 2009 was performed. Data were compared with published series.

RESULTS

A fistula was sought in 89 of 91 (98%) patients, and identified in 66 (73%). Recurrence occurred in 5/66 (8%) in whom a fistula was identified at the initial operation, compared with 6/25 (24%) (P = 0.06) in whom a fistula was not identified.

CONCLUSION

Recurrence of perianal infection is influenced by whether a fistula was identified and laid open at the initial operation. The recurrence rate is higher when the abscess is treated with incision and drainage alone. Given the ease with which most fistulae may be identified, and laid open without morbidity, optimal treatment involves drainage of the abscess and laying open of the fistulous tract.

Management of perianal abscess with hainosankyuto in neonates and young infants

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Fistula in ano in infants: who recurs?

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Anovestibular fistula with normal anal opening: Is it always congenital?

Aim:

To review 12 cases of anovestibular fistula with normal anal opening.

Methods:

Retrospective analysis of 12 children with anovestibular fistula and normal anal opening were treated between the years 2000 and 2007. Of these, 11 patients were diagnosed as having acquired anovestibular fistula with normal anal opening and were managed by conservative management.

Results:

Most of them presented with diarrhea and labial redness. One patient was considered to have fistula of congenital origin and was managed surgically. Eleven patients presented between the ages of 1.5–11 months and were considered as cases of acquired anovestibular fistula and only two of them required surgical management in the form of colostomy and fistula excision. Others were successfully managed by conservative treatment; the fistulous output and labial redness decreased gradually within a period of 5–19 (average 11.5) days.

Conclusions:

Not all presentations of anovestibular fistula with normal anal opening can be considered as congenital. Presence of inflammation, paramedian fistula, and a favourable response to conservative management/colostomy suggest acquired etiology. Trial of conservative management should be given in the acquired variety.

Nonoperative management of perianal abscess in infants is associated with decreased risk for fistula formation

OBJECTIVE

We sought to determine the frequency of progression in infants of perianal abscess with and without surgical drainage to fistula in ano to optimize a treatment plan for these children.

METHODS

A retrospective cohort study was conducted of all patients who were < or = 1 year of age and presented with perianal abscess to 2 pediatric tertiary care institutions during a 10-year period (January 1995 to February 2005, inclusive). Patients were divided into those who underwent surgical drainage and those who did not, and the rate of subsequent fistula formation was determined.

RESULTS

Of 165 children initially identified, follow-up was available for 140. Ninety-four percent of children were male. Mean age was 4.2 +/- 3.1 months. Of the 140 patients, 83 abscesses were drained and 57 were not drained. Of patients who underwent surgical drainage, 50 developed a fistula, whereas of those who did not undergo drainage only 9 developed a fistula. Synchronous administration of antibiotics (intravenous or oral) used in 57 of 58 patients from 1 institution was associated with an even greater decrease in fistula formation (12.5%) in the undrained population.

CONCLUSIONS

Perianal abscess formation in infants who are younger than 12 months is a separate entity from abscess formation in older age groups. In this largest study to date, a combined center series of patients who presented to 2 academic pediatric hospitals with infantile perianal abscess, local hygiene and systemic antibiotics without surgical drainage minimized formation of fistula in ano.

Treatment of fistula-in-ano in infants with a seton

Anal fistula in infants is a common disease. Although many are recovered by conventional treatment, there are some patients who are not repaired easily. We performed the seton method to an anal fistula and report the good result that we obtained.

[Perianal abscess and anal fistula in infancy and childhood. A congenital etiology?]

BACKGROUND

Perianal abscess and anal fistula in childhood are commonly treated in the same way as abscess and fistula in adults. We questioned whether they represent a cryptoglandular infection, as in adults, or two different diseases with the same symptoms.

MATERIALS AND METHODS

We retrospectively analyzed all medical records of 80 children (seven male, 73 female) who underwent surgical treatment for primary perianal abscess or primary anal fistula during a 10-year period. The records were analyzed concerning age at appearance of lesion, sex, diagnosis (fistula and/or abscess), and anatomic localization of the lesion.

RESULTS

Of all the children, 67.5% were treated during their 1st year of life and another 10% during their 2nd year (group 1: 77.5%, n=62). Only 22.5% were 3 or older (group 2, n=18). Group 1 contained significantly more male infants (m:f 30:1). However, much more balanced sex distribution was detected in group 2 (m:f 2.6:1), similarly to adults. Analyzing anatomic localization, a second important difference could be found: in contrast to group 2, almost two thirds of all anal fistulas/abscesses in group 1 were localized horizontally between 3:00 and 9:00 o'clock in crown-rump position.

CONCLUSIONS

Divergences in preference of age, sex, and localization suggest a congenital etiology for anal fistulas and perianal abscesses in children.

Common anorectal problems

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Transanal approach in repairing acquired rectovestibular fistula in females

AIM: To summarize the operative experience of the transanal approach in acquired rectovestibular fistula repair.

METHODS: Ninety-six cases of acquired rectovestibular fistula in young females were analyzed retrospectively. The etiology and operative procedure were discussed. Operative essential points were, the patient was laid in prone frog position, with the knees and hips flexed at 90^o; the perineum was elevated; and the anal opening was exposed. Four stay sutures were applied to the margin of the fistular orifice in the anal opening at points 3, 6, 9 and 12 o’clock. A circular incision of mucosa surrounding the stay sutures was made. The fistula was dissected from its anal opening to its vestibular opening. The wound of vestibule was sutured, and the rectoanal wound was then sutured transversely.

RESULTS: All the 96 patients recovered uneventfully from operation with a successful rate of 93.75%.

CONCLUSION: The transanal approach in the treatment of the acquired rectovestibular fistula is a simple and feasible technique.

Anorectal abscess fistula: what do we know?

Anorectal abscess and fistula are intimately connected in anatomy, etiology, and morbidity. They have been extensively described, but only sparingly studied in randomized controlled trials. These trials, covering such issues as primary suture of abscess, whether or not to perform a fistulotomy at the time of abscess drainage, and comparison of fistulotomy and fistulectomy, are the focus of this article. Important gaps in our knowledge and subjects for new trials are also discussed.

Fistula-in-ano in infants: is nonoperative management effective?

PURPOSE

Recently, a number of studies have reported positive results from the nonoperative management of fistula-in-ano in infancy, although it has not been of use in all patients. The purpose of this study was to discern the effective treatment methods of fistula-in-ano in infants.

METHODS

A retrospective review was done of 310 children who required operative management for fistula-in-ano or perianal abscess between January 1991 and July 2000. Eighteen patients displayed an onset of symptoms at less than 1 year of age and a duration of symptoms longer than 12 months. The authors analyzed these patients' medical records.

RESULTS

All patients were boys. The mean duration of the symptoms was 26.6 +/- 27.5 months. Fourteen patients had shown an onset of symptoms at less than 6 months of age. The longest duration was 10 years. The patients showed conservative periods of over 12 months because their parents did not want them to undergo surgery. The disease in these patients followed 2 patterns. One (6 patients) was an onset of symptoms followed by a silent fistula-in-ano state. The other (12 patients) was an onset of symptoms followed by an intermittent relapse of inflammation. All patients underwent fistulotomy, and none of them had recurrent fistula during the follow-up period.

CONCLUSIONS

Although the advantages of a nonoperative management of fistula-in-ano in infants include the avoidance of general anesthesia and surgical intervention, the lesions cannot be cured by a period of conservation. Surgical management is more effective in respect to the time factor.