Perianal abscess on call

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					Anorectal abscess on call

           Jim Hill
  Manchester Royal Infirmary
    Anorectal abscess distribution
   Perianal
        43-57%
   Ischiorectal
        23-34%
   Intrasphincteric
         7-21%
   Supralevator
         1- 8%
       Anorectal abscess – de Pezzer
      drainage – Isbister ANZJS 1987
   Local anaesthetic
   10% intolerable pain
   29% developed fistula
    in follow up period
  Anorectal abscess and fistula -
USA. A study of 1023 pts. Abcarian
   et al Dis Colon Rectum 1984

   Regional anaesthesia, early aggressive
    treatment of low fistula
   35% internal opening (3%
    sup/sphincteric)
   3.7% recurrence abscess only group
   1.8% recurrence primary fistulotomy
    group
Anorectal and fistula – UK. Winslett
    at al Dis Col Rectum 1988
   233 pts
   5% internal opening
   32% reoperation in incision and drainage
    category
   12% occult disease
       Anorectal abscess and fistula -
                 incidence

   Abcarian   35%
   Gordon     37%
   Mazier     69%
   Winslett    5%
     Primary fistulotomy-perianal
    abscess – Seow-Choen et al Dis
         Colon Rectum 1997
   Randomised trial 52 consecutive patients
   Persistent fistulas
       25% I&D group
        0% Fistulotomy group
   No difference in continence or ARPS
   Operating time, hospital stay, wound
    healing no different
    Early re-operation for anorectal
                abscess
   Onaca et al Mayo Dis Colon Rectum 2001
    500 consecutive patients, 627 procedures
    7.6% (48 pts) re-operation rate – 10 days
    23 incomplete drainage
    19 missed loculations/abscess
    Horseshoe abscess 50% failure rate
    Surgical error leading cause early
    failure
Horseshoe abscess
            Horseshoe abscess
   Drain bilaterally
   Ensure adequate skin
    excision
   Insert seton
Primary suture of anorectal abscess
 – Mortenson et al Dis Col Rectum
               1995
   Randomised trial 107 patients

       Clindamycin vs clindamycin and gentacoll

       Any fistula detected layed open

       Recurrence     17%       vs       22%




    
           Instructions to the BST
   Good News/low risk      Bad News/high risk

       Small abscess           Large, bilateral
       First abscess           Previous abscess
       Young                   Old
       Healthy                 Cardiorespiratory
                                 disease
                                Crohn’s disease
                                Fat
                                Obese
                                Immunosuppression
               Debriding agents

   Systemic review Health Technology
    Assessment 2001
       No good trials
       All used autolytic methods
       Modern dressings (foam, alginate,
        hydrocolloid) vs gauze
       Suggestion better than gauze for healing,
        pain, dressing performance and resource use
             Crohn’s disease

   Abscess always associated with a fistula
   Loose draining setons
   Avoid fistulotomy
   Recurrence rates >50% at two years
   Recurrence rates less in patients with
    stomas
Supralevator abscess

    Suspect intra-
     abdominal pathology
    Internal opening-
     seton drainage
    Supralevator
     component-
     mushroom catheters
    Haematological malignancies 1

   Incidence 7-10%
   Neutrophil count significant prognostic
    factor
   Mortality 20-50%
   Organisms same as non-
    immunocompromised patients
   Pus can form even in patients with severe
    neutropaenia
Haematological malignancies -2

   Evaluate rectal pain and fever carefully
   Start broad spectrum antibiotics
   Beware rapid progression to Fournier’s
   Incision and drainage when fluctuation
    present
   Role of surgery uncertain in non-resolving
    cellulitis
       HIV and perianal abscess

   Anorectal pathology not impacted by
    highly active antiviral therapy
   Disturbed wound healing more common
    (4-34%) and related to low CD4+ counts
    (< 200 x106)
   Serious septic complications higher (15%)
   Idiopathic anal canal ulcer commonly
    associated with inter-sphincteric abscess
    Acute pilonidal abscess – incision
              and drainage
   Br J Surg 1988 Jensen and Harling
       73 pts all had symptoms resolved
       58% healed primarily in 10 weeks
       12% later recurrence
       45% healed overall

       Increased recurrence rates in those with more
        pits and lateral sinus
Pilonidal abscess – primary closure
        with antibiotic cover
   Eur J Surg 1993
       56 patients one or four days ampicillin/flagyl
       30% recurrence
       No difference with antibiotic regimes
Perianal hidradenitis
                     Summary

   Train the BST
   Send pus and skin
   High risk cases
       Assess preoperatively
       Be present in theatre
   Low fistulas can be dealt with safely
   Use modern dressings
                           MCQ
   Which of the following statements with haematological
    malignancies and anal infections is true
    A. The development of a perianal abscess is independent
    from the granulocyte count
    B. The most common causative agent is candida
    C. The overall prognosis for the haematological cancer is
    independent from the prescence of septic complications
    D. The pus found at the time of the incision and
    drainage is identical to pus drained from common
    perianal abscesses
    E. Fever is an important element in the clinical
    presentation of such cases
Horseshoe abscess
            Horseshoe abscess
   Bilateral drainage
   Insertion of seton
    through internal
    opening
                    Radiology

   US scanning
       63% accuracy relation abscess and Park’
        classification
       28% accuracy locating internal opening

				
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