Transcript Perianal abscess on call

Anorectal abscess on call
Jim Hill
Manchester Royal Infirmary
Anorectal abscess distribution
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Perianal
43-57%
Ischiorectal
23-34%
Intrasphincteric
7-21%
Supralevator
1- 8%
Anorectal abscess – de Pezzer
drainage – Isbister ANZJS 1987
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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
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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
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233 pts
5% internal opening
32% reoperation in incision and drainage
category
12% occult disease
Anorectal abscess and fistula incidence
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Abcarian
Gordon
Mazier
Winslett
35%
37%
69%
5%
Primary fistulotomy-perianal
abscess – Seow-Choen et al Dis
Colon Rectum 1997
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Randomised trial 52 consecutive patients
Persistent fistulas
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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
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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
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Drain bilaterally
Ensure adequate skin
excision
Insert seton
Primary suture of anorectal abscess
– Mortenson et al Dis Col Rectum
1995
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Randomised trial 107 patients
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Clindamycin vs clindamycin and gentacoll
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Any fistula detected layed open
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Recurrence
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17%
vs
22%
Instructions to the BST
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Good News/low risk
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Small abscess
First abscess
Young
Healthy
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Bad News/high risk
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Large, bilateral
Previous abscess
Old
Cardiorespiratory
disease
Crohn’s disease
Fat
Obese
Immunosuppression
Debriding agents
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Systemic review Health Technology
Assessment 2001
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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
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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
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Suspect intraabdominal pathology
Internal openingseton drainage
Supralevator
componentmushroom catheters
Haematological malignancies 1
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Incidence 7-10%
Neutrophil count significant prognostic
factor
Mortality 20-50%
Organisms same as nonimmunocompromised patients
Pus can form even in patients with severe
neutropaenia
Haematological malignancies -2
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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
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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
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Br J Surg 1988 Jensen and Harling
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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
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Eur J Surg 1993
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56 patients one or four days ampicillin/flagyl
30% recurrence
No difference with antibiotic regimes
Perianal hidradenitis
Summary
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Train the BST
Send pus and skin
High risk cases
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Assess preoperatively
Be present in theatre
Low fistulas can be dealt with safely
Use modern dressings
MCQ
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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
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Bilateral drainage
Insertion of seton
through internal
opening
Radiology
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US scanning
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63% accuracy relation abscess and Park’
classification
28% accuracy locating internal opening