Perianal abscess and fistula-in-ano in children

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

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

Aerobic Microbiological Spectrum and Antibiotic Resistance in Children Operated for Anorectal Abscesses

(1) Background: Anorectal abscesses are a relatively rare pathology in childhood. Most often, male children under 1 year of age are affected. The importance of microbiological examination for the diagnosis and treatment of such patients remains debatable among surgeons, resulting in scarce data being available in the literature. We aimed to identify the aerobic microbiological spectrum and antibiotic resistance of isolates in children undergoing operation to treat anorectal abscesses. (2) Methods: We performed a case series of 102 children diagnosed and operated for anorectal abscesses over a period of 10 years (2010-2019). Purulent wound exudate was used for microbiological evaluation, which was subsequently cultured on 5% sheep-blood agar and eosin-methylene blue agar. For microbiological identification, conventional biochemical tests and semi-automated (API 20, bioMerieux, Marcy-l'Étoile, France) tests were used, as well as automated systems (Vitek-2 Compact, bioMerieux, France). Antimicrobial susceptibility testing was performed by the disk diffusion method of Bauer-Kirby and by determining the minimal inhibitory concentrations for glycopeptides. The results were interpreted according to the EUCAST standard for the corresponding year. (3) Results: Microbiological testing in children operated for anorectal abscesses mainly identified the gut commensals that normally reside in the rectal mucosa. Monocultures were found in just over half of the cases. Escherichia coli, Klebsiella pneumoniae complex, and Proteus mirabilis were the most frequently isolated. In addition, Staphylococcus aureus was found in 7% of patients. In Gram-negative bacteria, antibiotic resistance was most often observed in penicillins, cephalosporins, sulfonamides, and fluoroquinolones. (4) Conclusions: The increasing rates of antimicrobial resistance impose the need for the local monitoring of circulating commensal bacteria associated with anorectal abscesses in children to guide antibiotic therapy when indicated.

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.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

The optimal management of perianal abscess in children is controversial.

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Factors Increasing the Risk of Recurrence in Fistula-in-ano

Anal fistula, or fistula-in-ano, is a condition involving the anal region that is common yet debilitating. Surgery is the mainstay of treatment for an anal fistula and the chances of recurrence are quite high even after corrective surgical procedures. The risk factors for recurrence can be broadly classified into four categories: 1) risk factors related to the fundamental anatomy of the fistula and presence of comorbidities, 2) lack of proper preoperative assessment of the fistula, which includes failure to recognize the internal opening and overall structure of the fistula and not supplementing the proctologic examination with sufficient imaging, 3) intraoperative loopholes that include improper procedure selection, inexperience of the surgeon, and failure to get rid of the entire tract along with its ramifications, and 4) lack of proper postoperative care in the early and late periods following the surgery.

The aim of this paper, therefore, is to highlight the factors that could increase the risk of recurrence in different types of anal fistulae. Once surgeons know these risk factors, they can anticipate any complication and detect recurrence early.

[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.

Initial Experience with Fibrin Glue Treatment of Anal Fistulae in Children

Pediatric anal fistulae commonly result from recurrent perianal abscesses, of which nearly 50 per cent develop an anal fistula. The purpose of this study was to report the results of using fibrin glue to treat anal fistula in pediatric patients. Infants and children with recurrent perianal abscesses and anal fistulae were treated with either fistulectomy or fibrin glue. Demographic and clinical characteristics and outcomes were compared between the groups. A total of 34 children were included; 27 received fistulectomy (median age eight months) and seven received fibrin glue treatment (median age 14 months). No significant differences in demographic or clinical characteristics were found between the two groups (all, P > 0.05). Median follow-up duration was significantly higher in the fibrin glue group compared with that in the fistulectomy group (five months vs one month, P = 0.003). There was one recurrence in the fistulectomy group, and no recurrences in the fibrin glue group (P = 1.0). No complications occurred in either group. Fibrin glue treatment is a simple and effective treatment alternative in the management of anal fistula in children, offering the advantage of sphincter muscle-sparing and reduced risk of fecal incontinence.

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.

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.

Anorectal infection: abscess-fistula

Anorectal abscess and fistula are among the most common diseases encountered in adults. Abscess and fistula should be considered the acute and chronic phase of the same anorectal infection. Abscesses are thought to begin as an infection in the anal glands spreading into adjacent spaces and resulting in fistulas in ~40% of cases. The treatment of an anorectal abscess is early, adequate, dependent drainage. The treatment of a fistula, although surgical in all cases, is more complex due to the possibility of fecal incontinence as a result of sphincterotomy. Primary fistulotomy and cutting setons have the same incidence of fecal incontinence depending on the complexity of the fistula. So even though the aim of a surgical procedure is to cure a fistula, conservative management short of major sphincterotomy is warranted to preserve fecal incontinence. However, trading radical surgery for conservative (nonsphincter cutting) procedures such as a draining seton, fibrin sealant, anal fistula plug, endorectal advancement flap, dermal island flap, anoplasty, and LIFT (ligation of intersphincteric fistula tract) procedure all result in more recurrence/persistence requiring repeated operations in many cases. A surgeon dealing with fistulas on a regular basis must tailor various operations to the needs of the patient depending on the complexity of the fistula encountered.

Usefulness of bFGF spray in the treatment of perianal abscess and fistula-in-ano

PURPOSE

Basic fibroblast growth factor (bFGF) is a newly identified recombinant agent that promotes wound healing through an augmented neovascularization. This study examined the effect of bFGF in the treatment of perianal abscesses.

PATIENTS AND METHODS

Nine consecutive males with an average age of 5.1 months (1-9 months) who presented with perianal abscess in the past 2 years were treated with bFGF (Transfermin, Kaken Co., Ltd., Tokyo, Japan). Two or three sprays of bFGF were applied to the perianal abscess two times a day.

RESULTS

All nine patients responded well to the bFGF treatment. Pus discharge and local swelling around the fistula subsided within a mean of 7.3 ± 1.9 days (1 SD) after the initiation of treatment. One case showed a mild relapse 7 months after treatment and the other developed a new lesion 1 month after treatment. However, these lesions also similarly disappeared after a second treatment with bFGF without a recurrence in the follow-up examinations at 11 and 10 months, respectively. The remaining seven cases have all done well without any recurrence at a mean follow-up period of 14.1 ± 3.2 months.

CONCLUSION

These results clearly indicate the usefulness of the bFGF spray as a new treatment strategy for the management of perianal abscesses.

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.

[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.

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.

Treatment of perianal abscess and fistula-in-ano in children

Drain, don't probe

Perianal rhabdomyosarcoma presenting as a perirectal abscess: A report of 11 cases

BACKGROUND PURPOSE

The organs and soft tissues of the pelvis are some of the most common primary sites for rhabdomyosarcoma (RMS) in children and adolescents. In most cases a mass is detectable on clinical examination, and the initial concern is focused on the possibility of a neoplasm. The current report concerns 11 patients, each presented with a painful perineal-perianal mass suggesting an abscess to the extent that each one of these patients was treated initially with antibiotics or incision and drainage for several weeks to months before the pathologic diagnosis of RMS was established.

METHODS

The authors reviewed the clinical histories of all patients with perirectal/perianal RMS from their respective institutions to identify cases in which the initial clinical diagnosis or impression was that of a perirectal abscess. Pathologic material was reviewed in all cases.

RESULTS

Eleven patients, 7 of whom were girls, ranged in age from 1 to 16 years at diagnosis (median age, 14 years). Fever accompanied the clinical presentation in 2 patients. None of the patients had a past medical history of illness that may have predisposed them to a perirectal abscess, although one patient had a family history of inflammatory bowel disease. Duration of symptoms ranged from 1 month to 1 year (mean, 4.6 months). Each patient presented with a tender perianal/perineal nodule or mass. Inguinal adenopathy was present in 6 patients at diagnosis. White blood cell counts ranged from 6,600/mm(3) to 24,500/mm(3). LDH levels ranged from 414 to 3,432 U/L. The average time from presentation to pathologic diagnosis of RMS was 2.1 months. Nine of the 11 cases showed an alveolar pattern. All were high-stage disease. Of 7 patients with follow-up longer than 1 year, 2 (29%) are alive without disease.

CONCLUSION

This report presents the need to consider the possibility of a malignant neoplasm, in this case RMS, in a child or adolescent with a putative perirectal abscess that fails to respond in the expected manner to incision and drainage and antibiotic therapy.

Two cases of anal fistula in girls evaluated for sexual abuse

Anal fistulae are seen infrequently in the pediatric population. They are most commonly encountered in otherwise healthy boys less than 1 year of age. In the scant literature regarding pediatric anal fistulae, the majority of studies and case reports involve children less than 1 year of age. Within a 2-year period 2 school age girls presented to the authors' clinic with anal fistulae without history of a perianal abscess and without predisposing factors. Both of these children had a history of sexual abuse. We believe that in an otherwise healthy school age girl the appearance of an anal fistula should raise concern for the possibility of sexual abuse.

Perianal abscess and fistula-in-ano in infants

PURPOSE

The aim of this study was to obtain insight into the short- and long-term results of treatment of perianal abscess and fistula-in-ano in infants.

METHODS

This is a retrospective study of the records of patients treated over a 21-year period from January 1974 until December 1994 in a Pediatric Surgical Center. A long-term (1 to 24 year, mean 7.74 year) follow-up by questionnaire (response 81%) is also included.

RESULTS

Drainage of a perianal abscess is followed in 35% of cases by a fistula. Fistulotomy or fistulectomy is followed in 13% of cases by a recurrence. There were two long-term recurrences that both healed spontaneously. The persisting scar sometimes gives problems with anal cleaning. All children aged 3 years and older were continent for feces. In two, there was soiling for some time. One had constipation and one was incontinent during the night.

CONCLUSIONS

Simple drainage of a perianal abscess is followed frequently by a fistula. Fistulotomy or fistulectomy of a fistula-in-ano in infants has a reasonable chance of recurrence in the short term. Long-term recurrences are exceptional. There are no serious disabilities in the long run.

Anal fistula in infants: etiology, features, management

Anal fistulas in infants are poorly understood. A high incidence of recurrence has been attributed to a congenital abnormality of the anal crypts. To verify this hypothesis, we reviewed all anal fistulas seen in children less than 2 years of age and treated between 1980 and 1991. All patients were males with a mean age of 9.5 months, and only 3 had other illnesses. Ninety-two percent have had previous anorectal abscesses. The fistulas were single in 31 patients and double in 5. Their origin in the crypts was clearly identified in 14 cases. When anoscopy was routinely performed, deep thick-walled crypts were found in 47% of the cases. In most instances only one crypt was abnormal. The operative management included fistulotomy in 17 patients and fistulectomy in 9. Cryptotomies besides fistula excision were performed in 9 cases, and concurrent abscess drainage in 6. Follow-up was available in 31 patients for a mean length of 20 months. There were 4 complications (11%): one abscess requiring drainage, one wound infection treated conservatively, one granuloma, and one postoperative laryngitis. No recurrences were observed and none of the patients had fistula-related complaints at the last visit. Anal fistulas in infants are observed exclusively in males and are often related to abnormal crypts. Although 92% of fistulas are preceded by a perianal abscess, only 42% of perianal abscesses will result in fistula formation. Anal fistulas can be treated by either fistulotomy or fistulectomy.(ABSTRACT TRUNCATED AT 250 WORDS)