Multicentre observational study of outcomes after drainage of acute perianal abscess

European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula

AIM

The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology.

METHODS

Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG.

RESULTS

In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations.

CONCLUSION

This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.

Postoperative packing of perianal abscesses following incision and drainage

A best evidence topic in general surgery was written according to a structured protocol, to address the question: in adult patients with perianal abscesses, should postoperative wound packing be undertaken considering the rates of pain experienced, wound healing and abscess recurrence? The literature search identified 159 papers on Ovid, Embase and Medline and 48 on PubMed. These were independently screened, and three articles were included in this review as these offered the best information to answer the question. One was a systematic review without meta-analysis, one was a randomised controlled trial and one was a multicentre observational study. Review of these articles led the authors to conclude that routine postoperative packing of perianal abscesses following incision and drainage is costly, associated with increased pain and confers no protection against recurrence of abscesses or formation of fistulae.

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.

Study on the factors influencing the prognosis after perianal abscess surgery

OBJECTIVE

To study the influence of clinical characteristics and diagnosis and treatment methods of perianal abscess on postoperative recurrence or formation of anal fistula to provide a basis for selecting appropriate surgical and inspection methods for clinical treatment of perianal abscess in the future.

METHODS

The clinical data of 394 patients with perianal abscesses were collected, the influencing factors were investigated, and univariate analysis and multivariate logistic regression analysis were performed to further determine the risk factors affecting the prognosis of perianal abscess.

RESULTS

The results showed that the rate of preoperative blood routine results in the uncured group was higher (51.16%) than in the cured group (35.61%); the rate of high abscess space in the uncured group (23.26%) was higher than in the cured group (9.11%); the proportion of patients in the uncured group who underwent magnetic resonance imaging (MRI) before surgery (27.90%) was lower than in the cured group (45.30%); the proportion of patients in the uncured group who underwent simple drainage (51.16%) was higher than in the cured group (28.49%). The two groups had significant differences in perineal MRI examination, surgical method, preoperative blood routine, and abscess space (p = 0.030, p = 0.002, p = 0.047 and p = 0.010, respectively). Based on the results of univariate analysis and multivariate logistic regression analysis, the extent of the abscess cavity (OR = 2.544, 95%CI = 1.087-5.954, p = 0.031) and the surgical method (OR = 2.180, 95%CI = 1.091-4.357, p = 0.027) were independent influencing factors for postoperative recurrence of perianal abscess or anal fistula.

CONCLUSION

Preoperative assessment of the abscess range and precise intraoperative methods to resolve the infection of the abscess glands in the internal mouth can effectively improve the cure rate.

A case of reactive arthritis caused by a perianal abscess

Reactive arthritis is an immune-mediated aseptic arthritis resulting from either genitourinary or intestinal tract in a genetically susceptible host. Reactive arthritis is not uncommon, and the most common infectious agents are Chlamydia trachomatis, Salmonella, Yersinia, and Shigella, some new infectious agents include Staphylococcus lugdunensis, Rothia mucilaginosa, and umbilical cord-derived Wharton's jelly, as well as the SARS-CoV-2 virus, which has been more studied in recent years. We found that reactive arthritis caused by infection of perianal abscesses is very rare and few cases have been described in the medical literature. We report a 21-year-old man with polyarticular swelling and pain, and subcutaneous hematoma at his right ankle joint; he was considered reactive arthritis. After treating with non-steroidal anti-inflammatory drugs, sulfasalazine, surgery, and antibiotics, the patient's arthralgia gradually improved and the symptoms largely disappeared at the 1-month follow-up.

[Current WSES-AAST guidelines on anorectal emergencies-Summary and comments]

In 2019, the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) generated consensus recommendations for the treatment of anorectal emergencies in Parma, Italy, and published a guideline in 2021. This is the first global guideline dealing with this important topic for surgeons' everyday work. Seven anorectal emergencies were discussed and the guideline recommendations were given according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

Virtual reality distraction, a novel tool for pain alleviation during dressing change following surgical drainage of perianal abscess at Day Treatment Centre

Background

The pain induced by postoperative dressing changes adversely influence recovery and quality of life. In this study, we try to evaluate the pain alleviation effect of virtual reality (VR) distraction during postoperative dressing changes of patients who received surgical drainage of perianal abscess.

Methods

This was a prospective, randomized clinical trial. A total of 172 patients with perianal abscess were randomly assigned into control (only analgesics) and VR groups (VR distraction + analgesics). The pain and physiological measurements of all patients were collected before, during, and after the first dressing change following surgery. The difference in pain intensity and physiological parameters measurement between control and VR group was analyzed.

Results

The baseline characteristics of VR and control group were comparable (all P > 0.05). There was no significant difference in mean pain scores prior to and after dressing change between groups (both P > 0.05). Mean pain scores of 5, 10, 15, and 20 min measuring points during the first dressing change were significantly lower in the VR group compared with the control group (all P < 0.05). Pulse rates and oxygen saturation were not significantly different between groups.

Conclusion

VR can be used as an effective adjuvant pain distraction approach for postoperative dressing change.

Leukopenia is an independent risk factor for early postoperative complications following incision and drainage of anorectal abscess

AIM

Few data are available regarding the management of anorectal abscess in patients with leukopenia. The aim of this study was to investigate the impact of leukopenia among patients undergoing incision and drainage for anorectal abscess.

METHOD

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database identified patients from 2015 to 2020. Perianal fistulas and supralevator abscesses were excluded. Patients were grouped based on white blood cell (WBC) count: WBC < 4.5 cells/μl, WBC = 4.5-11.0 cells/μl and WBC > 11.0 cells/μl. The 30-day overall complications and outcomes were compared using regression models, accounting for demographics and comorbidities.

RESULTS

Ten thousand two hundred and forty (70.3% male) patients were identified. Univariate analysis showed that, compared with patients with leukocytosis (WBC > 11.0 cells/μl) and normal WBC count (WBC = 4.5-11.0 cells/μl), patients with leukopenia (WBC <4.5 cells/μl) had higher rates of overall (p < 0.001), pulmonary (p < 0.001) and haematological complications (p < 0.001). They also had higher rates of readmission (p < 0.001), reoperation (p = 0.005), discharge to a care facility (p = 0.003), increased length of hospital stay (p = 0.004) and death (p < 0.001). Multivariable analysis identified leukopenia as an independent risk factor for overall complications [odds ratio (OR) 2.31, 95% CI 1.65-3.24; p < 0.001], pulmonary complications (OR 5.65, 95% CI 1.88-16.97; p = 0.002), haematological complications (OR 4.30, 95% CI 2.94-6.28; p < 0.001), unplanned readmission (OR 2.20, 95% CI 1.43-3.40; p < 0.001), reoperation (OR 1.80, 95% CI 1.10-2.93; p = 0.019) and death (OR 2.77, 95% CI 1.02-7.52; p = 0.046). Discharge to a care facility and length of stay were not significant on multivariable analysis.

CONCLUSION

Leukopenia is associated with increased risk for pulmonary and haematological complications, readmissions, reoperations, discharge to a care facility and death after incision and drainage for anorectal abscess.

Clinical nursing visual health education pathway for patients with perianal abscess†

Objective: To investigate the effect of a clinical nursing pathway and visual health education on patients with perianal abscesses was the objective of this study.

Methods: Eighty patients with perianal abscesses undergoing in-patient surgical treatment (blinded for review) between December 2019 and November 2020 were divided randomly and evenly into a control group and an experimental group. The control group received routine nursing care, and the experimental group received visual health education nursing care. Digital pain scores, patient satisfaction scores, nursing quality scores, and scores measuring knowledge of perianal abscess disease for the two groups before and after nursing care were compared and analyzed.

Results: The experimental group had visual analog scale (VAS) scores significantly lower than those of the control group (P < 0.05). For total nursing satisfaction, the experimental group demonstrated a higher satisfaction rate (P < 0.05). Clinical nursing quality scores were significantly higher in the experimental group than those in the control group (P < 0.05). The perianal abscess disease-related knowledge scores after intervention were significantly higher in the experimental group than those in the control group (P < 0.01).

Conclusions: Visual health education nursing can help patients better understand and deal with perianal abscess disease.

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.

Postoperative Packing of Perianal Abscess Cavities (PPAC2): randomized clinical trial

BACKGROUND

Perianal abscess is common. Traditionally, postoperative perianal abscess cavities are managed with internal wound packing, a practice not supported by evidence. The aim of this randomized clinical trial (RCT) was to assess if non-packing is less painful and if it is associated with adverse outcomes.

METHODS

The Postoperative Packing of Perianal Abscess Cavities (PPAC2) trial was a multicentre, RCT (two-group parallel design) of adult participants admitted to an NHS hospital for incision and drainage of a primary perianal abscess. Participants were randomized 1:1 (via an online system) to receive continued postoperative wound packing or non-packing. Blinded data were collected via symptom diaries, telephone, and clinics over 6 months. The objective was to determine whether non-packing of perianal abscess cavities is less painful than packing, without an increase in perianal fistula or abscess recurrence. The primary outcome was pain (mean maximum pain score on a 100-point visual analogue scale).

RESULTS

Between February 2018 and March 2020, 433 participants (mean age 42 years) were randomized across 50 sites. Two hundred and thirteen participants allocated to packing reported higher pain scores than 220 allocated to non-packing (38.2 versus 28.2, mean difference 9.9; P < 0.0001). The occurrence of fistula-in-ano was low in both groups: 32/213 (15 per cent) in the packing group and 24/220 (11 per cent) in the non-packing group (OR 0.69, 95 per cent c.i. 0.39 to 1.22; P = 0.20). The proportion of patients with abscess recurrence was also low: 13/223 (6 per cent) in the non-packing group and 7/213 (3 per cent) in the packing group (OR 1.85, 95 per cent c.i. 0.72 to 4.73; P = 0.20).

CONCLUSION

Avoiding abscess cavity packing is less painful without a negative morbidity risk.

REGISTRATION NUMBER

ISRCTN93273484 (https://www.isrctn.com/ISRCTN93273484).

REGISTRATION NUMBER

NCT03315169 (http://clinicaltrials.gov).

Learning-by-teaching coming into play as a reliable trick for lower GI procedures: a learning curve analysis in 13,210 operative logs including the COVID-19 era

After suspecting a plunge in the operative case logs in our clinic, we wanted to explore the COVID-19 impact on surgical training side of the lower gastrointestinal procedures to raise awareness of the possible cracks in the pillars of general surgery residency. Comparing the coronavirus impact to previous years starting from 2014, we examined the procedures of our residents for their roles in the operating room. We performed interrupted time-series analyses to get a sense of the magnitude and then used a new index to identify the trend of change in operator-to-first assistant rate of experience and searched for signs of learning-by-teaching motives. In total, 13,210 operative logs of residents were included; of procedures, 3483 (41%) were emergency. Both overall resident participations and learning-by-teaching dropped during first 3 months, followed by a rebound. The overall operator-to-first assistant rate of experience was 1.06 before and 0.86 after. Emergency procedures, obstruction, perforation, enterostomy closure, appendix, colon, anus and minimally invasive procedures, and COVID-19 were associated with learning-by-teaching (OR and 95% Cl were; 2.20, 1.76–2.75; 0.56, 0.36–0.85; 0.50, 0.38–0.67; 2.29, 1.44–3.63; 11.09, 8.33–14.75; 1.75, 1.32–2.32; 2.56, 2.03–3.22; 0.80, 0.65–0.99 and 1.93, 1.54–2.42, respectively) (p < 0.05). The study provided insights into a vastly underrated surgical education subject: learning-by-teaching. The training index introduced here was a valuable learning curve instrument that has the capacity of comparing different training parameters or different residency programs. The surge in learning-by-teaching after the pandemic was interpreted as a reflex, processing the teaching as a training tool.

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.

Anorectal emergencies: WSES-AAST guidelines

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

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.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

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.

Treatment of Perianal Abscess and Fistula in Infants and Young Children: From Basic Etiology to Clinical Features

Perianal abscess and anal fistula are 2 common anorectal diseases in infants and young children. However, their causes, clinical diagnosis, and treatment remain controversial. Compared to adults, infants with these 2 diseases exhibit unique clinical characteristics. Blind pursuit of conservative treatment or surgery may worsen the condition, resulting in increased pain in young patients and greater economic burden and psychological harm to parents. Therefore, it is crucial to select correct and effective treatments. This review summarizes the relevant literature from the past 10 years and systematically explains the pathogenesis, clinical characteristics, and treatment measures of perianal abscess and anal fistula in infants with the goal of providing clinicians a deeper understanding of perianal abscess and anal fistula in infants and summarizing safe and effective treatment methods.

Medical-surgical Combined Approach in Perianal Fistulizing Crohn's Disease (CD): Doing it Together

Fistulising perianal Crohn's disease (pCD) is an aggressive phenotype, and patients not only suffer from perianal manifestations but also a worsening course for their luminal disease. This article describes the 6 key steps clinicians need to consider when managing patients with pCD which include; (i) ensuring a prompt diagnosis, (ii) multi-disciplinary management, (iii) psychological support, (iv) using multimodal medical and surgical treatment strategies, (v) continually monitoring and optimising therapy and (vi) ensuring that patients have a way of accessing care if required. Patients with fistulising pCD often have an unpredictable disease course and complete remission can be elusive. As such, a considered and nuanced approach is essential keeping the wider multi-disciplinary team and the patient involved in all decision making.

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.

Efficacy of continuous intravenous pumping of insulin for patients with diabetes complicated with perianal abscess and the effect on inflammatory cytokines

Efficacy of insulin with different administrations for patients with diabetes complicated with perianal abscess and the effect on serum inflammatory cytokines were investigated. One hundred and sixty-seven patients with type 2 diabetes who underwent radical operation of perianal abscess in Jinhua Hospital of Zhejiang University from January 2014 to December 2016 were analyzed. Before and after the operation, 89 patients who received continuous intravenous pumping of insulin for blood glucose control were set as an observation group, and 78 patients who received intermittent subcutaneous injection of insulin as a control group. The operative efficacy, wound healing time and 1-week postoperative growth of the granulation tissue were scored and compared. Fasting blood glucose (FBG) and 2 h postprandial blood glucose (2hPBG) before and after treatment were recorded and compared. Fasting venous blood was extracted before and on the 3rd and 7th days after operation to detect and compare serum inflammatory cytokines including tumor necrosis factor (TNF-α) and interleukin-6 (IL-6). Patients in the observation group had significantly higher total effective rate of the operation than that in the control group (P<0.05), and significantly shorter wound healing time and significantly lower growth score of the granulation tissue (P<0.05). Before treatment, there was no significant difference between the two groups in FBG and 2hPBG (P>0.05). After treatment, FBG and 2hPBG were significantly lower than those before treatment (P<0.050), and FBG and 2hPBG after treatment in the observation group were significantly lower than those in the control group (P<0.05). In conclusion, insulin pumps for injection during the perioperative period of patients with diabetes complicated with perianal abscess can better control the patients' blood glucose, improve the operative efficacy and promote the patients' postoperative healing. Moreover, continuous intravenous pumping of insulin is significantly better than traditional intermittent subcutaneous injection of it in controlling inflammation, so it is worthy of application.

Platelet-rich plasma (PRP) versus fibrin glue in cryptogenic fistula-in-ano: a phase III single-center, randomized, double-blind trial

PURPOSE

To compare the clinical outcome of autologous platelet-rich growth factor (PRP) with commercial fibrin glue in the management of high cryptogenic fistulae-in-ano.

METHOD

The study was conducted at a single center between July 2012 and July 2015 and performed as a phase III, randomized, double-blind comparison of autologously prepared PRP versus fibrin glue for cryptoglandular anal fistulae without active sepsis. Patients were assessed with clinical and endosonographic follow-up. Patients were followed up at 1 week and then at 3, 6, and 12 postoperative months. The primary outcome measure was the fistula healing rate (complete, partial, and non-healing) with secondary outcome measures assessing fistula recurrence, continence status, quality of life, and visual analog pain scores.

RESULTS

Of the 56 enrolled patients, 32 were PRP-treated and 24 were fibrin-treated. The groups were well matched for fistula type with an improved overall healing rate for PRP-treated over fibrin-treated cases (71% vs. 58.3%, respectively; P = 0.608); a complete healing rate of 48.4% vs. 41.7%, respectively; and a partial healing rate of 22.6% vs. 16.7%, respectively. The median pain scores of PRP-treated patients were lower at the first visit with a greater initial pain decrease early during follow-up. Improvements in pain reduction impacted the quality of life measures (P = 0.035). All adverse events were minor and no patient experienced a negative impact on continence.

CONCLUSION

Treatment of complex cryptoglandular anal fistula with autologous PRP is as effective as fibrin glue with less cost and no adverse effect on continence.

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.

Persistent Fistula After Anorectal Abscess Drainage: Local Experience of 11 Years

BACKGROUND

The characteristics of patients who develop a fistula-in-ano after an anorectal abscess are unclear.

OBJECTIVE

Our study explored this relationship and patient factors associated with fistula development.

DESIGN

International Classification of Diseases, 10 Revision, and Classification of Interventions and Procedures, version 4, codes were used to identify all of the patients with a primary anorectal abscess. Multivariable analysis was used to identify factors predictive of fistula formation.

SETTINGS

The study was conducted in a district general hospital.

PATIENTS

Patients with anorectal abscess who were admitted to our institution (2004-2015) were included.

MAIN OUTCOMES MEASURES

The rate of subsequent fistula formation was measured.

RESULTS

A total of 1970 abscess patients were identified; 70.0% (n = 1379) were men, and 7.3% (n = 144) had Crohn's disease. Fistulas occurred in 16.2% (n = 319) at a median of 7 months (interquartile range, 3-7 mo). Patients with Crohn's disease were more than twice as likely to develop a fistula than patients without Crohn's disease (32.6% vs 14.9%; OR = 2.5 (95% CI, 1.7-3.7); p < 0.001). Patients with Crohn's disease with a fistula were more likely to be women (55.3% vs 34.6%; p = 0.007) and aged <30 years (51.1% vs 24.3%; p< 0.001) versus patients without Crohn's disease with a fistula. At multivariable analysis of the entire cohort, male sex (OR = 0.7 (95% CI, 0.5-0.9); p = 0.005) and diabetes mellitus (OR = 0.5 (95% CI, 0.3-0.9); p = 0.027) were associated with a reduced likelihood of developing a fistula after abscess formation.

LIMITATIONS

The study was limited by its single-center scope, retrospective analysis, and lack of a standardized definition for Crohn's disease.

CONCLUSIONS

Abscesses are more common in men, but progression to fistula is more likely in women. The rate of fistula progression in Crohn's disease is twice that in patients without Crohn's disease. Identification of patients at risk may help delineate those who will benefit from a more conservative surgical approach, enhanced follow-up, or investigation after abscess drainage. See Video Abstract at http://links.lww.com/DCR/A798.

Incision & drainage of perianal sepsis in the immunocompromised: A need for heightened postoperative awareness

BACKGROUND

Incision and drainage of perianal sepsis has appreciable success in the immunocompetent population, but outcomes after incision and drainage in the immunosuppressed population are unknown.

METHODS

13,666 patients (n = 930 immunosuppressed) undergoing incision and drainage of perianal sepsis between 2011 and 2015 in the American College of Surgeons National Surgical Quality Improvement Program were identified. The main outcomes were major morbidity, return to the operating room, and mortality. Multivariable analysis was performed for each outcome.

RESULTS

Sepsis was the most common postoperative complication. Preoperative immunosuppression was an independent risk factor for major morbidity (odds ratio [OR]: 1.6, p < 0.01), return to the operating room (OR: 1.9, p < 0.01), and mortality (OR: 2.6, p < 0.01).

CONCLUSIONS

Immunosuppression is an independent risk factor for major morbidity, return to the operating room, and mortality. With post-operative sepsis the most common complication, inpatient admission and extended duration antibiotic therapy is warranted in immunosuppressed patients.

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.

Management of Common Benign Anorectal Disease: What All Physicians Need to Know

Benign anorectal conditions produce anal pain, rectal bleeding, or discharge from the perianal region, which are highly prevalent symptoms in the general population. Hemorrhoidal disease, anal fissure, perianal abscess, proctalgia syndromes, and pruritus anii are the most common clinical disorders. Well-trained physicians, irrespective of their specialty, can treat most of these disorders and refer them to a specialist in proctology only when necessary. The aim of this review is to provide a practical guide to the management of benign anorectal disorders in terms of their initial management and the criteria for specialist referral.

Natural history of anorectal sepsis

Background

Progression from anorectal abscess to fistula is poorly described and it remains unclear which patients develop a fistula following an abscess. The aim was to assess the burden of anorectal abscess and to identify risk factors for subsequent fistula formation.

Methods

The Hospital Episode Statistics database was used to identify all patients presenting with new anorectal abscesses. Cox regression analysis was undertaken to identify factors predictive of fistula formation.

Results

A total of 165 536 patients were identified in the database as having attended a hospital in England with an abscess for the first time between 1997 and 2012. Of these, 158 713 (95·9 per cent) had complete data for all variables and were included in this study, the remaining 6823 (4·1 per cent) with incomplete data were excluded from the study. The overall incidence rate of abscess was 20·2 per 100 000. The rate of subsequent fistula formation following an abscess was 15·5 per cent (23 012 of 148 286) in idiopathic cases and 41·6 per cent (4337 of 10 427 in patients with inflammatory bowel disease (IBD) (26·7 per cent coded concurrently as ulcerative colitis; 47·2 per cent coded as Crohn's disease). Of all patients who developed a fistula, 67·5 per cent did so within the first year. Independent predictors of fistula formation were: IBD, in particular Crohn's disease (hazard ratio (HR) 3·51; P &lt; 0·001), ulcerative colitis (HR 1·82; P &lt; 0·001), female sex (HR 1·18; P &lt; 0·001), age at time of first abscess 41–60 years (HR 1·85 versus less than 20 years; P &lt; 0·001), and intersphincteric (HR 1·53; P &lt; 0·001) or ischiorectal (HR 1·48; P &lt; 0·001) abscess location compared with perianal. Some 2·9 per cent of all patients presenting with a new abscess were subsequently diagnosed with Crohn's disease; the median time to diagnosis was 14 months.

Conclusion

The burden of anorectal sepsis is high, with subsequent fistula formation nearly three times more common in Crohn's disease than idiopathic disease, and female sex is an independent predictor of fistula formation following abscess drainage. Most fistulas form within the first year of presentation with an abscess.