Formation rate of secondary anal fistula after incision and drainage of perianal Sepsis and analysis of risk factors

Anal Cryptoglandular Suppuration: Evidence-Based Management

Anal suppurative processes are commonly encountered in surgical practice. While the initial therapeutic intervention is philosophically straightforward (incision and drainage), drainage of the appropriate space and treatment of the subsequent fistula in ano require a thorough understanding of perianal anatomy and nuanced decision making. Balancing the risk of fecal incontinence with simple fistulotomy versus the higher risk of fistula recurrence with all sphincter-sparing fistula treatments can be a challenge for surgeons and patients alike.

No Difference in the Pathogenic Microorganisms Among Different Types of Anorectal Abscesses: A Retrospective Study

OBJECTIVE

 There is limited data on the pathogenic microorganisms associated with anorectal abscesses. The purpose of this study was to retrospectively analyze the types and quantities of pathogenic microorganisms in the pus cultures of patients with anorectal abscesses and to explore the correlation between pathogenic microorganisms and types of anorectal abscesses.

METHODS

 A retrospective analysis was conducted on the microbiological data of 517 inpatient surgical patients with anorectal abscesses treated at a single center from January 2017 to December 2021. Chi-square tests were used to analyze whether there were differences in the types and quantities of pathogenic microorganisms among different types of anorectal abscesses.

RESULTS

 Among the 517 patients, the mean age was 38.5 years, with an average duration of illness of 7.4 days. Of these, 440 (85.1%) were male and 77 (14.9%) were female. The types of anorectal abscesses included perianal abscesses (54 cases, 10.4%), intersphincteric abscesses (253 cases, 48.9%), ischiorectal abscesses (129 cases, 25.0%), deep posterior anal space (DPAS) abscesses (26 cases, 5.0%), supra-levator abscesses (10 cases, 1.9%), and horseshoe abscesses (45 cases, 8.7%). A total of 23 different microorganisms were cultured from the 517 pus specimens. The most common microorganism was Escherichia coli (323 cases, 62.5%), followed by Klebsiella pneumoniae (77 cases, 14.9%), Bacteroides fragilis (nine cases, 1.7%), Pseudomonas aeruginosa (eight cases, 1.5%), and Staphylococcus aureus (seven cases, 1.4%). Additionally, no microorganisms were cultured from 58 (11.2%) pus specimens. Nine patients (1.7%) were admitted with concomitant necrotizing fasciitis. Among the nine cases of concurrent necrotizing fasciitis, E. coli, K. pneumoniae, and S. aureus were cultured in six (66.7%), two (22.2%), and one (11.1%) case, respectively. Chi-square tests revealed no significant differences in the types and quantities of pathogenic microorganisms among different types of anorectal abscesses (P > 0.05).

CONCLUSION

 This study provides a large sample of pus culture microbiological data from patients with anorectal abscesses. Regardless of whether it is a simple anorectal abscess or concurrent necrotizing fasciitis, E. coli was the most common microorganism cultured from the pus of patients with anorectal abscesses. Other common microorganisms include K. pneumoniae, B. fragilis, and S. aureus. These results provide evidence for the precise antibiotic treatment of anorectal abscesses. Additionally, there were no differences in the types and quantities of pathogenic microorganisms among different types of anorectal abscesses.

Enhancing surgical precision: unveiling the impact of preoperative colonoscopy in anal fistula patients

BACKGROUND

Anal fistula is a common benign anorectal disease that often requires surgical intervention for effective treatment. In recent years, preoperative colonoscopy as a diagnostic tool in patients with anal fistula has garnered increasing attention due to its potential clinical application value. By investigating underlying inflammatory bowel disease (IBD), polyps, and other abnormalities, preoperative colonoscopy can offer insights to refine surgical strategies and improve patient outcomes.

METHODS

This retrospective study focused on 1796 patients with various benign anorectal diseases who underwent preoperative intestinal endoscopy and met surgical criteria within the preceding three years at the First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine. Among these patients, 949 diagnosed with anal fistula comprised group A, while 847 patients without anal fistula were assigned to group B for comparison. The investigation encompassed an analysis of general patient information, endoscopic findings, polyp histopathology, distribution of bowel inflammation sites, and results of inflammatory bowel disease assessments between the two patient cohorts. A subgroup analysis was also conducted on 2275 anal fistula patients with no surgical contraindications. This subgroup was categorized into Group A (949 patients who underwent preoperative intestinal endoscopy) and Group C (1326 patients who did not undergo preoperative colonoscopy). The study compared the rates of detecting endoscopic lesions and IBD-related findings between the two subgroups.

RESULTS

The study initially confirmed the comparability of general patient information between groups A and B. Notably, the abnormal detection rate in group A was significantly higher than in group B (P < 0.01). In terms of endoscopic findings, the anal fistula group (group A) exhibited higher rates of detecting bowel inflammation, inflammatory bowel disease, and polyps compared to the non-anal fistula group (group B) (P < 0.05). The distribution of inflammation locations indicated higher detection rates in the terminal ileum, ileocecal region, and ascending colon for group A compared to group B (P < 0.05). Although the incidence of IBD in group A was higher than in group B, this difference did not reach statistical significance (P > 0.05). Subsequently, the analysis of the subgroup (groups A and C) revealed a significant disparity in intestinal endoscopic detection rates (P < 0.01) and statistically significant differences in detecting IBD (P < 0.05) and Crohn's disease (P < 0.05) between the two anal fistula subgroups.

CONCLUSIONS

The findings of this study underscore the substantial clinical value of preoperative colonoscopy in the comprehensive evaluation of patients with anal fistula. Preoperative colonoscopy aids in ruling out localized perianal lesions caused by underlying inflammatory bowel disease, thereby mitigating the likelihood of missed diagnoses and enhancing treatment outcomes. This research highlights the importance of incorporating preoperative colonoscopy as a valuable diagnostic tool in managing anal fistula patients.

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.

Comparison of contrast-enhanced fat-suppressed T1-3D-VIBE and T1-TSE MRI in evaluating anal fistula

OBJECTIVE

To evaluate the accuracy of contrast-enhanced (CE) fat-suppressed three-dimensional (3D) T1-weighted imaging with volumetric interpolated breath-hold examination (FS-T1-3D-VIBE) and fat-suppressed T1-weighted turbo spin echo (FS-T1-TSE) sequence in characteristics of anal fistula.

METHODS

One hundred and two patients underwent perianal CE-MRI examination on a 3T scanner including FS-T1-3D-VIBE and FS-T1-TSE sequences before surgery. The performance of each sequence was evaluated in terms of fistula classification, clarity of internal opening, number and position of internal openings including the distance between internal opening and anal verge, presence of secondary tracts and blind-ending sinus tracts. MRI findings were compared with surgical findings. Signal-to-noise ratios (SNRs) and contrast-to-noise ratios (CNRs) of fistula, gluteus maximus, and subcutaneous fat were compared between CE FS-T1-TSE and CE FS-T1-3D-VIBE.

RESULTS

Compared with CE FS-T1-TSE, CE FS-T1-3D-VIBE displayed more accurate in secondary tract, lithotomy position of the internal opening and the distance between internal opening and anal verge (P < 0.05). CE FS-T1-3D-VIBE was found superior to CE FS-T1-TSE in the clarity of the internal openings and in the diagnostic accuracy of blind-ending sinus tracts and complex fistulas in Standard Practice Task Force classification (P < 0.05). CE FS-T1-3D-VIBE achieved higher SNRs and CNRs in fistula and gluteus maximus than CE FS-T1-TSE (P ≤ 0.001).

CONCLUSION

CE-MRI of FS-T1-3D-VIBE might be a more valuable noninvasive technique than FS-T1-TSE to evaluate the anal fistula on evaluating the lithotomy position of internal opening, distance between internal opening and anal verge, clarity of internal opening, secondary tract, blind-ending sinus tract and classification of the complex fistula. The trial registration number for this prospective trial was Chi-TR1800020206 and the trial registration date was December 20, 2018.

Long term efficacy of Video-Assisted Anal Fistula Treatment (VAAFT) for complex fistula-in-ano: a single-centre Australian experience

BACKGROUND

Video-Assisted Anal Fistula Treatment (VAAFT) is a novel minimally invasive & sphincter-saving technique for treating complex fistula-in-ano involving endoscopic assessment & treatment of perianal fistula. This retrospective, non-randomized, observational study is the first Australian study of VAAFT. It is also the longest study of VAAFT to-date.

METHODS

From January 2014 to September 2019, 59 patients with a complex anal fistula were identified via MRI & underwent VAAFT. Fourteen patients had undergone previous definitive surgery for anal fistula. Specialized Karl Storz video equipment (fistuloscope) was used in the procedure. The rigid fistuloscope was used to directly visualize the fistula tract/s & internal opening. Closure of the internal opening was then performed. The fistula tract/s were then treated via fulguration. The external opening was kept patent & dressed. Patients were then followed up for a mean 59.5 months.

RESULTS

67.9% (n = 38) of patients achieved primary healing (needing nil further intervention) at a median of 13 weeks. 12.5% (n = 7) experienced healing followed by recurrence while 19.6% (n = 11) experienced non-healing. Of the recurrence/non-healing groups, 11/18 underwent repeat VAAFT with healing occurring in 10/11 patients at a median of 7 weeks. The mean operating time was 41.1 min. There were no major complications & continence scores were not affected. Three patients were lost to follow up.

CONCLUSION

VAAFT is both effective & safe for the treatment of complex fistula-in-ano. Its minimally invasive nature means that in the instance of recurrence or persistence, VAAFT can be repeated with minimal morbidity & reasonable likelihood of success.

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.

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.