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Benign Anorectal: Abscess and Fistula. Seema Izfar, MD. 12/21/11. Benign Anorectal: Abscess and Fistula. anorectal abscess and fistula-in-ano represent different stages of the same disease the abscess represents the acute inflammatory event the fistula represents the chronic process.

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benign anorectal abscess and fistula1
Benign Anorectal: Abscess and Fistula
  • anorectal abscess and fistula-in-ano represent different stages of the same disease
    • the abscess represents the acute inflammatory event
    • the fistula represents the chronic process
benign anorectal abscess and fistula2
Benign Anorectal: Abscess and Fistula
  • diagnosis and treatment requires in-depth understanding of anorectal anatomy and spaces
benign anorectal abscess and fistula3
Benign Anorectal: Abscess and Fistula
  • at the dentate line, the ducts of the anal glands empty into anal crypts
  • 80% are submucosal, 8% extend to internal sphincter, 8% to the conjoined longitudinal muscle, 2% intersphincteric, 1% penetrate internal sphincter
  • 90% of anorectal abscess result from crytogladular infection
  • Parks cryptoglandular theory - obstruction of anal glands leads to stasis and infection
  • classified by location: perianal, ischioanal, intersphincteric, supralevator
  • perianal abscess most common, supralevator most rare
  • pain, swelling, fever hallmark symptoms
    • supralevator abscess may have gluteal pain
    • rectal pain with urinary symptoms - possibly indicate intersphincteric or supralevator abscess
abscess etiology
Abscess - Etiology
  • nonspecific cryptoglandular (90%)
  • specific causes:
    • inflammatory bowel disease,
    • specific infection, ie TB, actinomycosis, lymphogranuloma venereum,
    • trauma or foreign body
    • surgery (episiotomy, hemorrhoidectomy, prostatectomy),
    • malignancy - carcinoma, lymphoma, radiation-related
abscess treatment
Abscess - Treatment
  • exam under anesthesia for pain out of proportion to exam
  • incision and drainage - trim edges to prevent coaptation
  • I&D of supralevator abscess:
    • depends on location - intersphincteric origin then divide internal sphincter and drain into rectum; if arises from ischianal abscess can be drained through perineal skin
abscess treatment1
Abscess - Treatment
  • catheter drainage: stab incision to drain pus, mushroom catheter in cavity to drain pus
    • make stab incision as close as possible to anus
    • size and length of catheter should correspond to abscess cavity
abscess treatment2
Abscess - Treatment
  • primary fistulotomy
      • may be easier to identify tract
      • eliminates source of infection
      • decreases recurrence/need for reoperation
  • downsides: false passage formation with acute inflammation, 30-50% of those with abscess likely won’t develop a fistula, need for anesthesia vs. local for I & D
abscess antibiotics
Abscess - Antibiotics
  • little or no role except in case of valvular heart disease, prosthetic devices, severe cellulitis, diabetes, immunosuppression
abscess complications
Abscess - Complications
  • Recurrence
    • recurrence in as many as 89% of pts
  • Extra-anal causes
    • should be evaluated for recurrent disease (hidradenitis suppurativa, Crohn’s)
  • Incontinence
    • iatrogenic (superficial external sphincter), inappropriate wound care (excessive scarring from prolonged packing)
abscess complications1
Abscess - Complications
  • can result in necrotizing anorectal infection (rare)
  • resuscitation, IV abx, wide debridement to healthy tissue
  • need for colostomy debatable - recommended if sphincter muscle is grossly infected, immunocompromised, rectal or colonic involvement/perforation
  • reexamination under anesthesia
  • HBO - 100% O2 at 3atm over 2 hrs - promote leukocyte phagocytic function and fibroblast proliferation
anal infection and hematologic diseases
Anal Infection and Hematologic Diseases
  • anorectal suppuration with acute leukemia with mortality 45-78%
  • neutrophil count <500 with 11% incidence of anorectal abscess
  • most important prognostic factor - # days of neutropenia
  • presenting symptoms: fever, pain, urinary retention
  • antibiotics vs I & D if fluctuance, sepsis, or progression of soft tissue infection after antibiotics trial
anal infection hiv
Anal Infection & HIV
  • HIV+ pts have increased risk of perianal sepsis
  • can be associated with in situ neoplasia
  • surgery + antibiotics 2/2 immunosuppression
    • make incison site small bc pts at risk for poor wound healing
fistula in ano
  • abnormal communication between any two epithelium-lined surfaces
  • Parks classification:
intersphincteric fistula in ano
Intersphincteric Fistula-in-ano
  • most common type of fistula - 70%
  • results from perianal abscess
  • variations:
    • simple low tract
    • high tract with rectal opening or blind tract
    • extrarectal extension
    • pelvic disease tracking
transsphincteric fistula
Transsphincteric Fistula
  • approx 23% fistulas
  • results from ischioanal absecesses
  • rectovaginal fistula is a form of transsphincteric fistula
  • operative mgt with setons if sphincter preservation in question
suprasphincteric fistula
Suprasphincteric Fistula
  • 5% of fistulas
  • result from supralevator abscesses
  • tract arises from intersphincteric abscess, travels above puborectalis, then downward lateral to external sphincters in ischioanal space
extrasphincteric fistula
Extrasphincteric Fistula
  • 2% of fistulas - rarest form
  • from rectum above the levators, through them, to the perianal skin
  • trauma, foreign body, Crohn’s carcinoma
  • most common cause is iatrogenic from probing during fistulotomy surgery
fistula in ano physical examination
Fistula-in-ano: Physical Examination
  • Goodsall’s rule:
    • transverse line across the perineum -
    • posterior external openings have internal openings in the posterior midline
    • anterior external openings have tract radially toward the nearest crypt
    • greater distance from anal margin with more variability
    • more accurate rule for posterior fistulas
fistula in ano treatment
Fistula-in-ano: Treatment
  • eliminate fistula,
  • prevent recurrence,
  • preserve sphincter function
fistula in ano treatment1
Fistula-in-ano: Treatment
  • identification of internal opening
    • passage of probe
    • injection of dye, milk, or hydrogen peroxide
    • following granulation in fistula tract
    • noting puckering of crypt with traction on fistula tract
fistula in ano operative management
Fistula-in-ano: Operative Management
  • Lay-open technique: identification of tract with unroofing tract +/- marsupialization
  • appropriate for simple interspincteric and low transsphincteric
fistula in ano operative management1
Fistula-in-ano: Operative Management
  • Seton - placement of non-absorbable suture material in fistula tract
  • indications for setons:
    • promote fibrosis around fistula tract that encircles entire sphincter mechanism
    • mark the site of fistula in massive anorectal sepsis
    • anterior high transsphincteric fistulas in women
    • HIV pts with poor wound healing and high transsphincteric fistulas
    • Crohn’s
    • any time continence is questioned
fistula in ano operative management2
Fistula-in-ano: Operative Management
  • high-transphincteric fistulas can be treated with combination lay-open technique and seton placement - division of internal sphincter to level of external opening and then seton placement
  • cutting setons can convert high fistulas to low fistulas
  • second-stage fistulotomy ~ 8 wks later
fistula in ano operative management3
Fistula-in-ano: Operative Management
  • suprasphincteric fistula - tract involves external sphincter and puborectalis -
    • can manage with division of internal sphincter and superficial external sphincter with seton around remaining ES
    • or internal sphincterotomy, seton, opening of fistula tracts without division of external sphincter
fistula in ano operative management4
Fistula-in-ano: Operative Management
  • Anorectal Advancement Flap
    • internal opening closed with absorbable suture, full-thickness flap of rectal mucosa/submucosa/IAS raised - adv 1 cm beyond internal opening
    • base of the flap should be twice the width of the apex
    • pros: reduction in healing time, reduced pain, little potential damage to sphincters, lack of deformity to anal canal
    • poor outcomes in Crohn’s, pts on steroids, smokers, o/w success reported in up to 90% of pts
fistula in ano operative management5
Fistula-in-ano: Operative Management
  • Fibrin Glue - used in conjuntion with AAF or alone
  • technique: internal and external openings identified, tract curetted, fistula tract injected through connector from external opening until glue visible in internal opening, slowly withdrawn
  • can be repeated several times without compromising continence
fistula in ano operative management6
Fistula-in-ano: Operative Management
  • Fibrin Glue - Followup:
  • short-term follow-up with good success 70-80%
  • longer follow-up with success falling to 60% and even 14% in pts with complex anal fistulas
fistula in ano operative management7
Fistula-in-ano: Operative Management
  • bioprosthetic fistula plug made from surgisis
  • technique - identification of internal and external opening with placement of plug over probe using suture similar to seton placement
  • plug secured at primary opening using absorbable suture
fistula in ano operative management8
Fistula-in-ano: Operative Management
  • technique works best with long tracts without active inflammation or sepsis
  • short-term follow up (3months) with higher success rate for Crohn’s fistulas when compared to fibrin glue
  • long-term follow up - high failure rate
crohn s and anal fistulas
Crohn’s and Anal Fistulas
  • the most common perianal manifestation and occur in 6-34% Crohn’s pts - pts with colonic Crohn’s with higher incidence, rectal Crohn’s with 100% fistula formation
  • conservative approach to treatment as 38% heal without surgery
crohn s and anal fistulas1
Crohn’s and Anal Fistulas
  • medications for treatment: cipro/flagyl, immunomodulators (steroids, 6MP, azathioprine, infliximab)
  • 6-MP and azathioprine only effective in 1/3 pts with fistulizing Crohn’s
  • Infliximab associated with 62% reduction
  • combination 6MP and infliximab may prolong effect of treatment
  • selective seton placement with infliximab + maintenance med with healing in 67%
crohn s and anal fistulas2
Crohn’s and Anal Fistulas
  • operative intervention: seton placement, rectal advancement flap if rectal-sparing, poss fibrin glue/plug
  • avoid cutting sphincter - incontinence reported in pts with Crohn’s proctitis even without anal surgery