Anorectal abscess-fistulae

Loose Thick Seton Suture Stimulates Rapid Healing and Lower Recurrence Rate in the Treatment of High Type Fistula in Ano

BACKGROUND: Fistula in ano is a chronic problem for the patients. It causes distressing because of foul odor and soiling with recurrent infection and discharge. Recurrence and anal sphincter injury were the most critical complications following surgery. Loose, thick seton placement was the most promising surgical operation. AIM: To reduce the time of seton placement, therefore, decreasing the suffering of patients from soiling and multiple dressing. PATIENTS AND METHODS: A retrospective study, one hundred patients with high type fistula in ano treated surgically in Al-Sader Medical city and Al-Najaf daily private clinic, Najaf city, Iraq, from February 2018 to March 2019. Fistulography and magnetic resonance imaging have taken from all patients. After that, fistulectomy with loose, thick seton suture placed for 3 months. Patients with the persistence of high fistula tract underwent a second surgery and third operation until complete healing. RESULTS: One hundred patients with high type fistula in ano with male 96 (96%) and female patients were 4 (4%). The rate of complete healing among male patients after the first operation was 90 (93%), while female patients showed a 4 (100%) rate of complete healing after the first operation. Three of the remaining male patients with persistently high fistula tract showed complete healing after the second operation, whereas 3 (3%) the rate of complete healing was 100% after the third operation. CONCLUSION: A loose, thick seton placed in high type fistula tract for 3 months provides excellent protection to the external anal sphincter with less recurrence rate and rapid healing.

Management of retrorectal supralevator abscess-results of a large cohort

PURPOSE

Proximal intersphincteric fistulas with proximal extension causing supralevatoric, retrorectal abscesses are a rare disease. There is only very limited experience, with small groups, and the limited published literature confirms the complexity of diagnostics and treatment. The aim of this study was to evaluate transrectal internal abscess drainage as planned definitive treatment.

METHODS

We retrospectively studied medical records of all patients with the diagnosis of retrorectal abscesses that underwent transrectal internal abscess drainage in the Department of Colo-proctology of the University Medical Centre Mannheim (2003-2012).

RESULTS

One hundred nine patients were operated on retrorectal abscesses, 70 (64.2%) men and 39 (35.8%) women. Mean age was 45.3 years (18-81). In 96 cases (88.1%), only a transrectal internal abscess drainage was performed as planned definitive treatment. Primary healing occurred in 60 patients (62.5%). A second transrectal internal drainage procedure was necessary in 27 cases (28.1%) to assure complete internal drainage. All secondary procedures led to subsequent healing. A combined surgical treatment due to coexisting fistula tracts to the perianal skin or additional ischioanal abscesses was required in 13 patients (11.9%), and an additional seton placement was performed. Nine patients (9.4%) underwent one or more reoperations due to previously unidentified complex coexisting fistulas. Most of these patients were immunosuppressed due to Crohn's disease. Internal drainage alone was successful in 90.6% with an overall healing rate of 94.5% for the entire population of complex fistulas.

CONCLUSIONS

Transrectal internal abscess drainage is a safe and highly successful procedure for treatment of retrorectal abscess, with very low risk of postoperative fecal incontinence. Inflammatory bowel disease and immunosuppressives have a negative impact on the healing process.

Management of cryptoglandular supralevator abscesses in the magnetic resonance imaging era: a case series

AIM

The aim of this study is to describe the diagnostic performance of magnetic resonance imaging in the management of supralevator abscess, regarding its origin, location, drainage route, subsequent treatment of the fistula, and long-term results.

METHODS

A retrospective case series including thirteen consecutive patients with cryptoglandular supralevator abscess treated between 2001 and 2011 at a colorectal unit of a tertiary referral center. A magnetic resonance imaging was performed in all patients before surgical drainage, and its usefulness in assessing supralevator abscess origin was analyzed. Short- and long-term results after drainage were also evaluated.

RESULTS

The final diagnosis of supralevator abscess and the location described in the magnetic resonance were confirmed intraoperatively in all patients. An ischiorectal origin was identified in nine patients, and perineal translevator drainage was performed placing a mushroom catheter through the ischiorectal or the postanal space. Four patients underwent secondary treatment of anal fistula: two rectal advancement flap and two non-cutting seton. In the other four patients, an intersphincteric origin was identified and transanal surgical drainage was performed placing a long-term mushroom catheter. Several weeks later, transanal unroofing of the residual cavity was performed and the fistula lay open to the anorectal lumen. In the long-term follow-up (median 61 months), only patients with supralevator abscess of ischiorectal origin in whom fistula was not subsequently treated presented a recurrence of the anal sepsis.

CONCLUSIONS

Magnetic resonance imaging seems essential to clarify the location of supralevator abscess, its origin, and choice of the right drainage route. Subsequent treatment of the fistula is necessary to avoid recurrence.

The distribution of the anal glands and the variable regional occurrence of fistula-in-ano: is there a relationship?

BACKGROUND

Fistula in ano is a rather common condition, but the disease process is not yet fully understood. The aim of our study was to determine how the distribution of anal glands contributes to the variable occurrence of fistula-in-ano in the perineum.

METHODS

we conducted a blinded two-phase prospective study. In the first phase, the perineum of the patients with primary fistulae was anatomically divided into right upper and lower and left upper and lower quadrants in the lithotomy position. The fistulae were classified according to what quadrant the external and internal openings and the tract pathway were in. In the second phase, using 10 human cadaver specimens, full thickness tissue samples were taken from each quadrant of the anus. Samples were histologically evaluated for the volume fractions of the anal glands in each quadrant.

RESULTS

The new classification system we propose revealed that the largest number of fistulae 43% (17/39) were in the right lower quadrant, and 22% (9/39), 12% (5/39) and 8% (3/39) were in the left lower, right upper and left upper quadrants, respectively. It was also observed that 14% (5/39) of fistulae were in more than one quadrant. The volume fractions of each quadrant showed that the largest volume fraction of the anal glands was in the right lower quadrant (right lower quadrant: 0.64, left lower quadrant: 0.35, right upper quadrant: 0.26 and left upper quadrant: 0.22, P = 0.001).

CONCLUSIONS

To the best of our knowledge, this is the first study that has objectively shown that the distribution of the anal glands is variable, and the highest density of anal glands is in the right lower quadrant of the anus. This variable distribution may be associated with the variable occurrence in fistula in ano.

Outcomes after fistulotomy: results of a prospective, multicenter regional study

PURPOSE

This study aimed to determine the outcomes and healing rate after fistula surgery across a broad spectrum of colorectal practices.

METHODS

A prospective, multicenter outcomes registry was created by the New England Regional Chapter of The American Society of Colon and Rectal Surgeons. All consecutive patients undergoing surgical treatment of an anal fistula by a participating surgeon from October 1, 2007 to September 30, 2008, were entered. Demographics, fistula characteristics including Parks' classification, smoking history, previous vaginal deliveries, diagnosis of Crohn's disease, Fecal Incontinence Severity Index, and operations performed were noted. A follow-up datasheet recorded postoperative complications, healing at one and three months, and postoperative continence scores. Factors associated with healing and treatment success were compared by use of Fisher's exact test.

RESULTS

Twenty-five surgeons at 13 hospitals entered 245 patients (162 male, 83 female) in the registry. Seventy-five patients had recurrent fistulas, 51 had multiple tracts, 62 were smokers, and 24 had Crohn's disease. The overall healing rate was 19.5% at one month and 63.2% at three months. Female gender (P = 0.04) and recurrent fistula (P = 0.03) were associated with nonhealing, and 28.4% of patients required additional surgery. The best healing rate was associated with fistulotomy (87%), whereas a plug had the worst healing rate (32%, P = 0.001).

CONCLUSIONS

Surgical treatment of an anal fistula is associated with a substantial risk of nonhealing at three months. Fistulotomy had a high success rate, whereas the bioprosthetic plug had the lowest success rate. Multicenter studies comparing treatment options for similar fistulas are needed.

A new seton type for the treatment of anal fistula

In this retrospective study, our aim was to introduce an industrial synthetic material that can be used as a seton and then to present the results of complicated anal fistula cases treated with this different sort of seton. Between 1997 and 2005, 32 patients (aged 27-63 years) with a high anal or rectal internal opening were treated with a cutting seton. In the postoperative period none of the patients had recurrence or solid stool incontinence. However, three of them had just flatus incontinence, and two had flatus and liquid stool incontinence. The new material we used as a new type of seton can be used efficiently; it can be inserted easily, is cheap and effective, and may give better therapeutic results and better patient satisfaction.

Management of intersphincteric abscesses

OBJECTIVE

Intersphincteric abscesses are relatively rare, and in some cases of upward extensions in the supralevator plane, can be difficult to manage. The aim of this study was to analyse the type of treatment used in these abscesses.

METHODS

Twenty-one intersphincteric abscesses treated by endoanal drainage in our colorectal unit between 1992 and 2004 were reviewed from our database; location and extension of the abscess, type of treatment and recurrence rates and the use of endoanal ultrasound were studied.

RESULTS

Ninety per cent of patients were male; 10 had a previous history of surgery for perianal abscess and suppuration (48%); 16 (76%) had a posterior location and five were anterolateral. Twelve patients had low intersphincteric abscesses and were treated by laying open the abscess and dividing the internal sphincter. Nine were found to have high extensions into the intermuscular planes and were treated by staged procedures: a temporary transanal mushroom catheter was used in seven patients. Endoanal ultrasound was used initially in seven patients (33.3%) and for the evaluation of definitive treatment in 11 (52%).

CONCLUSIONS

Low intersphincteric abscesses should be treated by de-roofing of the abscess and division of the internal sphincter up to a level of the dentate line. High intersphincteric abscesses are relatively frequent and mostly require staged surgery with a temporary mushroom (de Pezzer) catheter. Accurate anatomical ultrasound localization and proper drainage become important to avoid recurrences or extrasphincteric fistulas.

Venous oxygen embolism produced by injection of hydrogen peroxide into an enterocutaneous fistula

We report a venous oxygen embolism that occurred in a 66-yr-old man after 60 mL of 3% hydrogen peroxide was injected into a perianal fistula intraoperatively to locate its internal opening. The diagnosis was made after detecting hypoxemia, decreased end-tidal carbon dioxide tension, systemic hypotension, increased central venous pressure, and a new heart murmur. The patient recovered quickly and had no long-term sequelae. Oxygen embolism is a potentially fatal complication that can develop when hydrogen peroxide is used near venous spaces, and clinicians should be aware of the potential dangers when using this seemingly innocuous chemical.

Perianal infections: reader agreement and diagnostic performance of fat-suppressed contrast-enhanced MRI

We aimed to determine the diagnostic performance of the contrast-enhanced fat-suppression technique in the detectability of perianal infections and to compare this technique with different MR sequences used for this purpose. Thirty consecutive patients with clinically suspected anorectal infections were examined with fast spin-echo (FSE) T2-weighted, short-inversion-time inversion recovery (STIR), and fat-suppressed and non-fat-suppressed T1-weighted spoiled gradient-echo (SGE) (in-phase) dynamic contrast-enhanced sequences. The results of MRI were correlated with the findings of surgery, which was considered as the standard of reference. Receiver-operating-characteristic curves were reconstructed to describe and compare the diagnostic value of each MR technique. The values of kappa were used as a measure of observer reliability. Diagnostic performances of STIR, FSE T2-weighted and fat-suppressed and non-fat-suppressed, contrast-enhanced SGE T1-weighted techniques showed statistically insignificant differences in detection of perianal infections. There was almost perfect interobserver agreement regarding the presence of lesions on each MR technique. Fat-suppressed, contrast-enhanced SGE T1-weighted MRI showed adequate diagnostic performance in the detection of perianal infections. However, its significance is not different from the other MR sequences used for the present study.

Anorectal abscesses: need for accurate anatomical localization of the disease

Anorectal abscesses constitute a common problem of the perianal area. Considerable morbidity is expected if an immediate and anatomically correct drainage procedure is not performed in a timely manner. Acute infection of an anal gland leads to the formation of the anorectal abscess, while the chronic stage of the infection appears as a fistula in ano. It is imperative to perform operations with accurate anatomical knowledge; this is particularly true in the case of fistula-in-ano and anorectal abscesses, for which inappropriate surgery can lead to disastrous results. Here we report our experience with anorectal abscesses in various locations in 14 patients. Four of the 14 had a transrectal drainage. The internal (transrectal) or external drainage of the anorectal abscesses depends mainly on the mechanism of their formation and the anatomical relationship of the abscess to the levator ani. Apart from a death occurring 1 month after drainage due to a cause not related to suppurative disease (subdural hematoma), all patients had an uneventful recovery and were discharged from hospital after a mean stay of 1.2 days. A brief and practical description of the macroscopic anatomy of the area will assist in understanding better the selection of the appropriate route of drainage of anorectal abscesses.

Anorectal Disease

Most symptomatic internal hemorrhoids, grade 1 through 3, can be treated successfully with office-based procedures. Anorectal suppurative diseases must be treated surgically. Control of sepsis with subsequent fistula surgery as necessary is the goal. New nonoperative methods of anal fissure therapy are directed at reducing anal sphincter pressures. These methods have shown significant reduction in the need for sphincterotomy--a proven surgical technique with some risk of impaired continence. Surgery, using an advancement flap and partial internal sphincterotomy, remains the primary treatment for anal stenosis. Solitary rectal ulcer remains a difficult problem to manage medically and surgically. Multiple surgical techniques can effectively treat rectal prolapse. A minimal technique using Silastic wrap (Wright Medical Technologies; Arlington, TX), perineal resection (Altemeier procedure), and sigmoidectomy-rectopexy, or Ripstein suspension, has been the most favored method in selected patients.

Prognostic value of magnetic resonance imaging in the management of fistula-in-ano

PURPOSE

Magnetic resonance imaging of fistula-in-ano has been shown to predict surgical anatomy accurately and identify complex features. In addition, fistula complexity has been correlated with poor outcome after surgical intervention. We investigated whether preoperative magnetic resonance imaging could predict clinical outcome after surgery for fistulous disease better than clinical examination under anesthetic.

METHODS

Seventy patients with clinically suspected fistula-in-ano underwent preoperative dynamic contrast-enhanced magnetic resonance imaging before surgical exploration. Outcome was assessed at a minimum of one year after surgical exploration and correlated in a blinded fashion with the surgical and magnetic resonance grading of the severity of the fistulous disease.

RESULTS

Of 70 patients, 12 were not operated on and 6 were lost to follow-up, making 52 patients eligible for analysis. Assessment by dynamic contrast-enhanced magnetic resonance imaging more accurately predicted outcome than the findings at initial surgical exploration. Dynamic contrast-enhanced magnetic resonance imaging had a sensitivity of 81 percent, specificity of 73 percent, and positive predictive value of 75 percent; surgery had a sensitivity of 77 percent, specificity of 46 percent, and positive predictive value of 59 percent. Surgical assessment of apparent disease severity bore no relation to final outcome. Dynamic contrast-enhanced magnetic resonance imaging could accurately predict whether patients were likely to have a satisfactory or unsatisfactory outcome after surgery.

CONCLUSION

Dynamic contrast-enhanced magnetic resonance imaging better predicts clinical outcome of patients with fistula-in-ano than initial surgical exploration.

Endoanal advancement flap repair for complex anorectal fistulas

BACKGROUND

Most anorectal fistulas may be safely and reliably treated by fistulotomy. However, certain complex fistulas (e.g., rectovaginal fistulas, high transsphincteric tracts, Crohn's disease) are not well suited to this technique. Few satisfactory alternatives exist. The aim of this study was to assess the utility of endoanal advancement flap repair for these difficult fistulas.

METHODS

Thirty-three consecutive patients underwent endoanal advancement flap repair of a complex anorectal fistula. Patients were followed up via a prospective database. Demographic information, the presence of previous fistula surgery, and surgical complications were noted. Patients were closely followed up until healing of the fistula or treatment failure was noted.

RESULTS

The overall initial healing rate was 81% (27 of 33). However, 3 patients with perianal Crohn's disease ultimately developed a recurrent fistula. There were no major complications and two minor urinary complications. No patient required hospital readmission, and there were no new problems with fecal incontinence. No patient required a colostomy.

CONCLUSION

Endoanal advancement flap repair is effective in a variety of difficult, complicated anorectal fistulas. Since the morbidity is quite low, it should be attempted prior to fecal diversion, when possible, in these settings.

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.

Outcome after surgery for perianal fistula: predictive value of MR imaging

OBJECTIVE

The purpose of this study was to determine if MR findings are predictive of long-term outcome in a cohort of patients whose initial surgery was performed without access to the findings of MR imaging.

SUBJECTS AND METHODS

Forty patients with surgically proven perianal fistulas underwent preoperative dynamic contrast-enhanced MR imaging. The MR and surgical findings were independently recorded on an identical anatomic form. Three patients were subsequently lost to follow-up. The outcome for the remaining 37 patients was determined from surgical review, case notes, and questionnaires. Minimum follow-up period was 14 months (range, 14-39 months). Outcome was determined by one observer who was unaware of the initial MR grading and had not been present during surgery. Outcome was considered unsatisfactory if further surgery was required.

RESULTS

MR imaging was better than surgical exploration in predicting outcome (for MR imaging: positive predictive value, 73%; negative predictive value, 87%; sensitivity, 89%; and specificity, 68%; for surgical exploration: positive predictive value, 57%; negative predictive value, 64%; sensitivity, 73%; and specificity, 47%). MR classification of fistulas was significantly associated with outcome (p = .0004), and surgical classification was not significantly associated with outcome (p = .22, chi-square test). Also MR grades differed significantly for patients with satisfactory and unsatisfactory outcomes (p < .001, Mann-Whitney U test).

CONCLUSION

MR imaging is valuable in the management of patients with perianal fistulas. MR imaging accurately reveals surgical anatomy and can be used to make better predictions regarding patient outcome than surgical findings.

Anorectal disorders

Anorectal disorders are commonly encountered in the practice of emergency medicine. Most can be diagnosed and treated in the emergency department setting. Almost all anorectal disorders once diagnosed and treated in the emergency department need appropriate follow-up to ensure adequacy of treatment, for further possible diagnostic procedures (e.g., endoscopy, biopsy), or for definitive treatment. Hemorrhoids are the most prevalent anorectal disorder and are the most common cause of hematochezia. Treatment is dependent on the degree of hemorrhoid prolapse and symptoms. Most cases can be treated by conservative medical treatment (e.g., dietary changes, sitz baths) or nonsurgical procedures (e.g., rubber band liagation, infrared coagulation). Surgical excision of symptomatic thrombosed external hemorrhoids is indicated if within 48 to 72 hours of pain onset. Anal fissures are one of the most common causes of anorectal pain. They are most frequently idiopathic, and most are located in the posterior midline of the anal canal. Most anal fissures are adequately treated by a medical approach using sitz baths, stool softeners, and analgesics. If the anal fissure becomes chronic and is not responsive to medical therapy, a lateral sphincterotomy of the internal anal sphincter is the surgical procedure of choice. Pharmacologic treatment (botulinum toxin or nitroglycerin ointment) to decrease internal anal sphincter tone has shown promise in the treatment of anal fissure. Anorectal abscesses are categorized into four types: perianal, ischiorectal, intersphincteric, and supralevator. Most are idiopathic and contain mixed aerobic-anaerobic pathogens. Fistula formation varies from 25% to 50% and is much more common with gut-derived organisms (e.g., E. coli, B. fragilis). Definitive treatment for an anorectal abscess is timely surgical incision and drainage to prevent more serious complications (e.g., serious infection, extension of the abscess). Anal carcinomas are infrequent, the majority of them being squamous cell or epidermoid carcinomas. The emergency physician must maintain a high index of suspicion and obtain a biopsy of suspicious lesions in order not to miss the diagnosis of a cancer. The most common presenting complaint of anal tumors is rectal bleeding. Combination chemotherapy and radiotherapy have shown promising results in the treatment of anal canal tumors. Bacterial, viral, and protozoal infections can be transmitted to the anorectum via anoreceptive intercourse. Such infections must be considered when a patient presents with rectal pain or discharge, tenesmus, or rectal or perineal ulcers. Proctosigmoidoscopy and rectal cultures may be necessary to determine the cause. Potential rectal complications of HIV infection include infectious diarrhea, acyclovir-resistant strains of HSV2, Kaposi's sarcoma, lymphoma, and squamous cell carcinoma. Rectal injuries may result from penetrating or blunt trauma, iatrogenic injuries, or foreign bodies. Rectal injury should be suspected when a patient presents with low abdominal, pelvic, or perineal pain or blood per rectum after sustaining trauma or undergoing an endoscopic or surgical procedure. Tetanus prophylaxis, intravenous antibiotics, and surgical intervention are indicated in all but superficial rectal tears.