Complicated anorectal sepsis

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.

Management of Perianal Sepsis in Immunosuppressed Patients

Despite improvements in the supportive care of immunosuppressed patients controversy still surrounds the surgical management and outcome of anorectal sepsis in these patients. We reviewed 83 immunocompromised patients with diagnosis of perianal sepsis from 1995 to 1997. Sixty-six patients (80%) were followed for a mean of 15 months. Mean age was 44 years and 76 per cent were males. Twenty-eight per cent were HIV+, 34 per cent had inflammatory bowel disease on steroids, 20 per cent had malignancies, and 18 per cent had diabetes. Twenty-eight per cent had anal fistula, 2 per cent had perianal abscess, and 40 per cent had both. Primary sites of fistula were: transsphincteric (38%), intersphincteric (33%), superficial (20%), and suprasphincteric (3%), and multiple tracks (6%). Horseshoeing was present in 14 per cent of cases. The most commonly practiced surgical procedures were primary fistulotomy (n = 23) and fistulotomy plus drainage (n = 28). Seven patients underwent fistulotomy and ostomy and eight patients were treated with fistulectomy plus drainage. Most wounds (91%) healed within 8 weeks. Incontinence (6%) and recurrence (7%) were the most commonly observed complications. These results are similar to those seen in the general population. Perianal sepsis can be safely managed in immunocompromised patients, with high rates of healing and low complication rates. An aggressive sphincter-preserving approach in the management of these patients may be undertaken.

Subcutaneous fistulectomy in bridging hidradenitis suppurativa

BACKGROUND

The treatment of chronic lesions in hidradenitis suppurativa remains a challenge. For some clinical types surgical management is an excellent alternative.

OBJECTIVE

This study evaluates an alternative surgical approach for the treatment of hidradenitis suppurativa of specific bridging lesions by subcutaneous resection of the tubular fibrotic tissue.

METHODS

Periorificial fusiform skin incisions were made around the orifices parallel to the axillary or inguinal folds and the subcutaneous tubular fibrotic tissue was removed en bloc before skin suturing.

RESULTS

The outcome was evaluated as satisfactory due to lower morbidity, minimizing the excised skin areas, prevention of bridles or adherences, shorter incisions, no healing difficulties, and less dehiscence or wound exposure.

CONCLUSION

The subcutaneous fistulectomy is a surgical option in bridging hidradenitis suppurativa.

Viral infections of the gastrointestinal tract

Acute gastroenteritis is common in adults. It can occur in institutional epidemics or epidemics of food-borne illness; in these cases, caliciviruses are the major cause of the condition. When acute gastroenteritis occurs in nonepidemic form, its causes are less clear. It may be due to caliciviruses or to the less common serotypes of childhood gastroenteritis viruses, such as rotavirus, astrovirus, and adenovirus. The pathogenesis of acute viral gastroenteritis is not completely understood. Old evidence suggests that mild villus damage is responsible, but new evidence indicates that active secretion and motility disturbance may be involved in the production of symptoms. Five common viruses can remain latent in gastrointestinal tissues and produce disease many years after initial infection. Two major herpesviruses, cytomegalovirus and herpes simplex virus, cause ulcerative disease of the gastrointestinal tract. This disease occurs in healthy persons but is more common and more severe in immunocompromised patients. Three other viruses--Epstein-Barr virus, human papilloma virus, and human herpesvirus-8--are implicated in benign and malignant proliferative diseases of the gastrointestinal tract. Epstein-Barr virus has been associated with immunoproliferative disease after transplantation and may also cause small-bowel and colonic lymphoma in healthy adults. It causes most AIDS-related lymphomas. Human papillomaviruses cause anorectal condyloma and anal cancer. Human herpesvirus-8 causes gastrointestinal Kaposi sarcoma.

Anorectal miscellany: pilonidal disease, anal cancer, Bowen's and Paget's diseases, foreign bodies, and hidradenitis suppurativa

Pilonidal disease commonly is seen by all primary care practitioners, and guidelines for office management and referral are provided. Less commonly seen entities, such as hidradenitis suppurativa, anal cancer, and Bowen's and Paget's diseases, also may affect this anatomic area. Knowledge that they may be encountered here helps guide the practitioner to the proper diagnosis and management. Lastly, foreign bodies are sometimes seen in the anorectal area, and information about appropriate steps to take are outlined.

Anorectal abscess and fistula

Anorectal abscesses and fistulas are seen commonly in the primary care practice. An abscess forms as the result of obstruction of an anal gland, with resulting retrograde infection. An anal fistula simply represents the chronic phase of a perianal abscess. The history generally is diagnostic, and special studies usually are not required. Treatment is surgical, with good results.