Anorectal abscess on call Jim Hill Manchester Royal Infirmary

Anorectal abscess distribution Perianal 43-57% Perianal 43-57% Ischiorectal 23-34% Ischiorectal 23-34% Intrasphincteric 7-21% Intrasphincteric 7-21% Supralevator 1- 8% Supralevator 1- 8%

Anorectal abscess – de Pezzer drainage – Isbister ANZJS 1987 Local anaesthetic Local anaesthetic 10% intolerable pain 10% intolerable pain 29% developed fistula in follow up period 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 Regional anaesthesia, early aggressive treatment of low fistula 35% internal opening (3% sup/sphincteric) 35% internal opening (3% sup/sphincteric) 3.7% recurrence abscess only group 3.7% recurrence abscess only group 1.8% recurrence primary fistulotomy group 1.8% recurrence primary fistulotomy group

Anorectal and fistula – UK. Winslett at al Dis Col Rectum pts 233 pts 5% internal opening 5% internal opening 32% reoperation in incision and drainage category 32% reoperation in incision and drainage category 12% occult disease 12% occult disease

Anorectal abscess and fistula - incidence Abcarian35% Abcarian35% Gordon37% Gordon37% Mazier69% Mazier69% Winslett 5% Winslett 5%

Primary fistulotomy-perianal abscess – Seow-Choen et al Dis Colon Rectum 1997 Randomised trial 52 consecutive patients Randomised trial 52 consecutive patients Persistent fistulas Persistent fistulas 25% I&D group 25% I&D group 0% Fistulotomy group 0% Fistulotomy group No difference in continence or ARPS No difference in continence or ARPS Operating time, hospital stay, wound healing no different Operating time, hospital stay, wound healing no different

Early re-operation for anorectal abscess Onaca et al Mayo Dis Colon Rectum 2001 Onaca et al Mayo Dis Colon Rectum 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

Drain bilaterally Drain bilaterally Ensure adequate skin excision Ensure adequate skin excision Insert seton Insert seton

Primary suture of anorectal abscess – Mortenson et al Dis Col Rectum 1995 Randomised trial 107 patients Randomised trial 107 patients Clindamycin vs clindamycin and gentacoll Clindamycin vs clindamycin and gentacoll Any fistula detected layed open Any fistula detected layed open Recurrence 17% vs 22% Recurrence 17% vs 22%

Instructions to the BST Good News/low risk Good News/low risk Small abscess Small abscess First abscess First abscess Young Young Healthy Healthy Bad News/high risk Bad News/high risk Large, bilateral Previous abscess Old Cardiorespiratory disease Crohn’s disease Fat Obese Immunosuppression

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

Crohn’s disease Abscess always associated with a fistula Abscess always associated with a fistula Loose draining setons Loose draining setons Avoid fistulotomy Avoid fistulotomy Recurrence rates >50% at two years Recurrence rates >50% at two years Recurrence rates less in patients with stomas Recurrence rates less in patients with stomas

Supralevator abscess Suspect intra- abdominal pathology Suspect intra- abdominal pathology Internal opening- seton drainage Internal opening- seton drainage Supralevator component- mushroom catheters Supralevator component- mushroom catheters

Haematological malignancies 1 Incidence 7-10% Incidence 7-10% Neutrophil count significant prognostic factor Neutrophil count significant prognostic factor Mortality 20-50% Mortality 20-50% Organisms same as non- immunocompromised patients Organisms same as non- immunocompromised patients Pus can form even in patients with severe neutropaenia Pus can form even in patients with severe neutropaenia

Haematological malignancies -2 Evaluate rectal pain and fever carefully Evaluate rectal pain and fever carefully Start broad spectrum antibiotics Start broad spectrum antibiotics Beware rapid progression to Fournier’s Beware rapid progression to Fournier’s Incision and drainage when fluctuation present Incision and drainage when fluctuation present Role of surgery uncertain in non-resolving cellulitis Role of surgery uncertain in non-resolving cellulitis

HIV and perianal abscess Anorectal pathology not impacted by highly active antiviral therapy Anorectal pathology not impacted by highly active antiviral therapy Disturbed wound healing more common (4-34%) and related to low CD4 + counts (< 200 x10 6 ) Disturbed wound healing more common (4-34%) and related to low CD4 + counts (< 200 x10 6 ) Serious septic complications higher (15%) Serious septic complications higher (15%) Idiopathic anal canal ulcer commonly associated with inter-sphincteric abscess Idiopathic anal canal ulcer commonly associated with inter-sphincteric abscess

Acute pilonidal abscess – incision and drainage Br J Surg 1988 Jensen and Harling Br J Surg 1988 Jensen and Harling 73 pts all had symptoms resolved 73 pts all had symptoms resolved 58% healed primarily in 10 weeks 58% healed primarily in 10 weeks 12% later recurrence 12% later recurrence 45% healed overall 45% healed overall Increased recurrence rates in those with more pits and lateral sinus Increased recurrence rates in those with more pits and lateral sinus

Pilonidal abscess – primary closure with antibiotic cover Eur J Surg 1993 Eur J Surg patients one or four days ampicillin/flagyl 56 patients one or four days ampicillin/flagyl 30% recurrence 30% recurrence No difference with antibiotic regimes No difference with antibiotic regimes

Perianal hidradenitis

Summary Train the BST Train the BST Send pus and skin Send pus and skin High risk cases High risk cases Assess preoperatively Assess preoperatively Be present in theatre Be present in theatre Low fistulas can be dealt with safely Low fistulas can be dealt with safely Use modern dressings Use modern dressings

MCQ Which of the following statements with haematological malignancies and anal infections is true 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

Bilateral drainage Bilateral drainage Insertion of seton through internal opening Insertion of seton through internal opening

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