Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_923_Библиотеки_им_академика_М_И_Перельмана.pdf
11.21 Whether toPerform Primary Fistulotomy inPatients withAnorectal Abscess!
171
11.21 Whether toPerform Primary
Fistulotomy inPatients
withAnorectal Abscess!
The Surgeon’s Dilemma!
It is a subject of controversy [31]. Aggressive
intervention in the inamed tissue can sometimes
create a false passage and lead to unnecessary
sphincter division [32, 33]. Instead of primary stulotomy, many surgeons prefer to wait for the stula to appear [32]. It is estimated that subsequent
stulas follow 34–50% of horseshoe abscesses.
Random clinical trials were conducted as a metaanalysis suggesting that primary stulotomy
reduces subsequent stula formation by 83% [34].
Assessing the extent of external anal sphincter
involved is the deciding factor in whether primary stulotomy should be performed. A primary stulotomy is not recommended for those
with Crohn’s disease or immunocompromised
patients. In such situations, a draining seton is the
best option [35].
In females, the perineal body is a weak structure. The length of the external sphincter anteriorly is half compared to males. One should
therefore avoid doing stulotomy to prevent
incontinence [35].
McElwain et al., in 1975, was the rst to
advocate primary stulectomy (not stulotomy)
for infection of cryptoglandular origin when
abscess and stula were considered to be two
separate entities [36]. Lockhart-Mummery
strongly objected to performing primary stulectomy in the hands of young surgeons due to
difculty in assessing the sphincter complex in
the presence of inammation [37]. He strongly
advocated against carrying out any probing to
avoid false passage formation. This statement
holds good even today.
In my opinion, performing a primary stulotomy is a surgeon’s choice. He should have a good
command of anatomy lest he causes sphincter
damage. When the anatomy of the sphincters is
evident during the surgery, a primary stulotomy
can be undertaken [38]. As stated earlier, the
probe should always be inserted from the internal
opening outwards and not the other way to avoid
the creation of an iatrogenic opening.
11.21.1 Absolute Contraindications
forPrimary Fistulotomy
• A high trans-sphincteric stula with more
than 50% posterior involvement of the external sphincter
• A trans-sphincteric stula with massive ano-
rectal sepsis where the anatomy of sphincters
is distorted
• High trans-sphincteric stula with associated
poorly managed immunodeciency disease
[38]
• High trans-sphincteric stula in Crohn’s dis-
ease [38]
• The presence of an anterior stula in females
11.21.2 Tips andTricks ofDoing
Primary Fistulotomy
A solution of hydrogen peroxide and methylene
blue is injected into the abscess after needle
aspiration of the pus. If bubbles are seen at the
internal opening on the dentate line, and the
anatomy of the sphincters is precise, I prefer to
do primary stulotomy. Another criterion that I
keep in mind is the length of the tract. If the tract
appears to be less than 3 cm, I prefer to lay it
open. On the contrary, if the tract is more than
3cm, and the anatomy of sphincters is not precise, I prefer to place a draining seton for 3
months for maturation of the tract and carry out
a minimally invasive hybrid procedure afterwards (Fig.11.20a–d).
172
cd
11 Evaluation andManagement ofAnorectal Abscess
a
b
Fig. 11.20 (a–d) Primary stulotomy. (a) Injecting
hydrogen peroxide and methylene blue through perianal
abscess at 3 o’clock. (b) Dye is seen coming out of the
internal opening at 12 o’clock (c) primary stulotomy is
11.22 Complications ofAnorectal
Abscess
done at 3 o’clock position (d) Excision of internal opening and mucosa, submucosa, and surrounding tissue to
remove primary source of infection
• Sitz bath twice a day.
• Laxative once or twice a day. In my practice, I
use osmotic laxatives as the bulk laxatives
• Septicemia
• Recurrence
• Fistula formation
• Fecal incontinence (due to the disease or as a
surgical complication) [19]
form bulky stools, which may lead to pain
during defecation.
• An ointment containing metronidazole,
sucralfate, and lidocaine is used for local
application. Metronidazole controls anaerobic
infection. Sucralfate forms a protective barrier
over the raw area and promotes healing [39].
11.23 Postoperative Care
• Start with broad-spectrum antibiotics and wait
for the pus culture and sensitivity report.
Lidocaine acts as a local anesthetic agent.
The patients are called for follow-up after
10days.
11.24 Case Studies
173
11.24 Case Studies
In whichever part of the world we practice as surgeons, the clinical presentations of the patients
and postoperative complications remain the
same. However, the extent of complications may
differ depending on one’s expertise.
Case 1
A male patient aged 65 came for consultation. He
was operated on for hemorrhoidectomy 2 years
back. Since then, he used to feel some restriction
during defecation. He consulted one of the surgeons, who operated on him for posthemorrhoidectomy anal canal mucosal stenosis. After a few
days of the surgery, he developed a dull pain in
the perianal region that gradually worsened,
became consistent and throbbing in nature, and
had difculty sitting. When the patient came, he
had unbearable pain. On examination, there was
a tender swelling in the perianal region at 11–12
o’clock near the anal verge. On DRE, an internal
opening at 12 o’clock could be palpated. An MRI
was recommended, which showed a small focal
area of altered signal in the anterior perianal
region at 12 o’clock, suggestive of perianal
abscess with communicating intersphincteric
tract. The need for surgical intervention was
explained, to which he readily agreed. Abscess
drainage with primary stulotomy was planned.
Under spinal anesthesia, the patient was placed in
a lithotomy position. The pus was aspirated from
the abscess cavity. Then methylene blue and
hydrogen peroxide solution were injected through
the swelling, and bubbles were observed to come
out of an internal opening at 12 o’clock. The perianal abscess was drained near the anal verge, and
the abscess cavity was curetted. The tract was
opened up to the internal opening by a primary
stulotomy followed by marsupialization. The
patient was immediately relieved of pain.
Postoperative wound care was explained to him,
and his wound completely healed in 4weeks.
Opinion
I opted for primary stulotomy because once
the dye was injected into the abscess cavity, I
could see the dye coming out from an internal
opening, indicating a communicating tract. If a
perianal abscess has a communicating intersphincteric stula, abscess drainage followed by
primary stulotomy should be done.
Case 2
A 40-year-old patient who was operated on for
laser hemorrhoidoplasty at our center came for
follow-up on the fourth postoperative day. He
looked miserable as he had pain in and around
the anal region. He was terried and refused a
rectal examination but was calmed down. He was
given an analgesic. After the pain reduced, he
was examined. Mild postoperative edema was
present. Analgesic and diclofenac suppository
was prescribed. He was assured that the pain was
due to postlaser edema that would subside with
the analgesics. The medication did not work, the
pain worsened, and he came back to the OPD
with the complaint of fever. He had severe pain
and pus discharge from the anal canal. His hemogram was done, which showed a raised leucocyte
count. On examination, swelling in the perianal
region had increased, and an internal opening at 7
o’clock could be made out. An MRI revealed a
complex elongated collection with a curvilinear
stulous tract with inammatory changes, suggestive of perianal abscess with intersphincter
stula. After explaining the need for surgery, he
was taken for abscess drainage. Pus discharge
could be seen from the internal opening at 7
o’clock. The perianal abscess was drained, and a
primary stulotomy for the intersphincteric stula was done. The abscess healed, and the patient
was satised.
Opinion
Laser energy is bactericidal, as justied by
many publications; therefore, abscess formation
postlaser is rare. In my practice, after laser hemorrhoidoplasty, I have come across 3 patients with
perianal abscesses out of almost a 1000 cases. The
probable reason could be an infection from the
local site. The anal area contains fecal matter,
which can cause infection if it travels through the
entry point of the laser ber. Secondly, the infection could have occurred through the mucosa
punctured during hemorrhoidal artery ligation.
174
11 Evaluation andManagement ofAnorectal Abscess
Case 3
A 38-year-old male patient walked into my OPD,
moaning and unable to stand. His attendant told
me that the patient had hemorrhoids and went to
a local physician who did sclerotherapy. He
developed severe pain on the third day. He consulted the same physician who prescribed him
antibiotics, but the patient got no relief after medication. After that, he consulted one of my colleagues, who suggested an MRI. The MRI
revealed a horseshoe abscess in the intersphincteric plane extending to form a large intersphincteric and perianal abscess, prominently on the left
side, with communication seen posterior to the
anal canal with edema in the levator ani. Transsphincteric and intersphincteric stulous tracts
were noted. The patient was referred to me for an
opinion and further management. On examination of the ischiorectal area, no rubor or swelling
could be seen or palpated. However, on DRE,
there was a sizable internal opening at 6 o’clock.
As the patient had a lot of pain, I could not carry
out the proctoscopy.
On the operating table, after inserting a halfcut proctoscope under spinal anesthesia, to my
surprise, I could not nd any signs of thrombosed
or strangulated hemorrhoids following sclerotherapy which I was expecting. On pressing the
ischiorectal fossa, no pus could be seen coming
out. A probe was inserted and could be seen
going towards deep postanal space. The space
was opened by making an incision on the lower
internal sphincter. The incision was also made on
the external sphincter’s subcutaneous and supercial parts. While operating, an extension of the
abscess from the intersphincteric plane toward
the levators was seen, which was curetted and
irrigated. The patient got immediate relief from
pain; he was kept under observation for 48 h.
However, the soaking of the dressing pad was
evident at the time of discharge which reduced
from the fth postoperative day. The patient was
explained about postoperative cleaning of the
wound and maintenance of hygiene.
Opinion
In this case, the infection started after injection sclerotherapy, which is a known procedural
complication. Most important is to ascertain the
site of an abscess. In this case of a horseshoe
abscess, the pathway of spread was from the posterior midline crypt. As discussed earlier, no surgical procedure is complete without opening the
deep postanal space. The infective process will
not eradicate if the deep postanal abscess is not
drained.
Case 4
Mrs. X, a middle-aged woman, came with a
complaint of pain in the anal region for 1 month.
The pain was more during and after defecation,
sometimes coming on half an hour after defecation. She also complained of bright red bleeding
and burning after defecation. So much so that
even the water she used to clean the area caused
pain and burning. There was no history of pus
discharge. On examination, a minor swelling
near the anal region was present. A nontender
swelling in the right ischiorectal area could be
palpated. No signs of inammation were evident. There was a mild increase in the anal tone
on digital rectal examination. At the 6 o’clock
position, an internal opening and some bogginess towards the 9 o’clock position could be
made out. She was referred for an MRI, which
suggested an ischiorectal abscess traversing
posterior- superiorly toward the midline, crossing the external and internal sphincter and the
internal opening at 6 o’clock. The tract measured
6cm in length.
She was taken up for surgery after administrating spinal anesthesia. A needle was inserted
into the abscess cavity, and 1mL of pus was aspirated. Methylene blue and hydrogen peroxide
were injected into the abscess, and bubbles were
seen coming out of the internal opening. An incision was made on the abscess’s most medial margin, and the pus was drained. An artery forceps
was inserted, and through the internal opening, it
was brought out from an incision site of the
abscess. A trans-sphincteric tract could be seen
going posteriorly. The entire tract over the forceps was laid open by cutting the internal anal
sphincter and the supercial and subcutaneous
part of the external anal sphincter. The abscess
cavity and the tract were curetted. The internal
opening, mucosa, submucosa, and surrounding
11.24 Case Studies
175
tissue were excised, and the necrotic material
was sent for histopathological examination. The
surgery was concluded by doing marsupialization of the margins of the stulotomy wound. The
patient had postoperative pain for 3–4days but
gradually recovered and was completely ne in
6–7weeks.
Opinion
The most crucial preoperative nding was the
assessment of the sphincter anatomy. The patient
had an ischiorectal abscess with a communicating trans-sphincteric stula. Had there been any
problem in assessing the extent of the sphincter
involved, I would have done seton placement. As
the extent of sphincter involvement was evident
and I was sure about not cutting more than 50%
of the external anal sphincter posteriorly, primary
stulotomy could be carried out comfortably.
Case 5
Mrs. G, a 39-year-old female, was successfully
operated upon by one of my colleagues for drainage of a perianal abscess and got well, but after a
few months, an abscess formed again at the same
site. She consulted her surgeon and was again
operated on for incision and drainage of the
abscess. After being disease-free for a year, she
developed vague pain in the anal region. She
came for consultation. On local examination,
there were no clinical ndings. On digital rectal
examination, induration was palpated at 6 o’clock
with bogginess toward the right levators. She was
referred for an MRI, which suggested a supralevator abscess. Subsequently, she was operated on
for the transanal opening of the intersphincteric
space with drainage of supralevator abscess with
stulotomy. The 6 o’clock internal opening was
excised for to reach the intersphincteric space. A
probe inserted through an internal opening was
seen going toward the supralevator extension.
The tract was curetted followed by irrigation, and
the necrotic material was sent for histopathology.
A stulotomy was done up to the anal verge from
the wound created after excising the internal
opening to allow drainage of the collection. The
patient was advised to follow the postoperative
instructions and milking of the intersphincteric
space when applying the ointment (a combina-
tion of metrogyl, lignocaine, and sucralfate). The
patient fully recovered after 6weeks.
Opinion
A paradigm shift of draining the supralevator
abscess through transanal approach, formed as an
upward extension of intersphincteric abscess
from the dentate line, gave satisfactory results.
Milking of the abscess cavity was advised to
avoid collection in the intersphincteric space.
Lately, in the presence of a supralevator abscess,
I prefer to open the intersphincteric plane. Proper
drainage of the abscess is achieved, and the
results have been satisfactory.
Case 6
A 52-year-old gentleman came to the OPD with
complaints of swelling near the anal region and
pain while sitting for the last 15days. He was a
known case of diabetes mellitus. Clinically, there
was a perianal abscess at 5 o’clock with an internal opening at 6 o’clock on the dentate line. His
MRI revealed a perianal abscess extending to the
gluteal region with a communicating transsphincteric stula with a 6 o’clock internal opening. A mild collection was seen in the deep
postanal space.
The need for surgery was explained to the
patient and his relatives. Abscess drainage with
primary stulotomy for trans-sphincteric stula
was planned. Under spinal anesthesia, the patient
was positioned in a lithotomy position. Pus was
seen coming out of the internal opening. The
abscess cavity was demarcated. Hydrogen peroxide and methylene blue were injected through the
medial most part of the abscess near the 5 o’clock
position, about 3.5cm from the anal verge. Dye
was seen coming out of the internal opening at 6
o’clock. A stab incision with 11 number blade
was given over the most medial part of the
abscess close to the anal verge. Methylene bluestained pus was seen coming out of the incision
site. A blunt artery forceps was inserted through
the incision, and a primary stulotomy was carried out.
Another vertical incision was made over the
anococcygeal ligament to reach the deep postanal
space (Modied Hanley’s procedure).
Communication was seen between the abscess
176
ab
ef
cd
11 Evaluation andManagement ofAnorectal Abscess
cavity and the deep postanal space. A seton was
placed for drainage of the abscess. The ischioanal
abscess cavity extending for about 6cm posteriorly was curetted, followed by irrigation with
normal saline. Another nick was given over the
most dependent part of the abscess, and a draining seton was placed. The internal opening,
mucosa, and submucosa were excised.
Marsupialization of the margins of the stulotomy wound was done (refer Fig.11.21a–i).
Fig. 11.21 (a) Injecting H2O2 and methylene blue
through the most medial part of the abscess. (b) Bubbles
seen coming out of 6 o’clock internal opening. (c) A stab
incision with 11 number blades on the most medial part of
the abscess. (d) Primary stulotomy performed from
internal opening. (e) Vertical incision given over anococcygeal ligament for entering the deep postanal space. (f)
Seton placement in the deep postanal space communicating with stulotomy wound. An incision given over the
most dependent part of the abscess posteriorly. (g)
Placement of the seton to prevent collection in the abscess
cavity. (h) Marsupialization of stulotomy edges. (i) Final
postoperative picture after completion of the procedure
gh
11.25 Discussion
i
177
Fig. 11.21 (continued)
Opinion
As the patient had an ischioanal abscess with
a communicating trans-sphincteric stula involving less than 50% of the external anal sphincter,
abscess drainage with primary stulotomy was
ideal. Without opening the deep postanal space,
any abscess cavity with deep-seated pus collection would not heal. Modied Hanley’s procedure was carried out. After 3 days, the setons
were removed as there was no residual collection,
and the induration completely subsided.
path of minimal resistance and is named according to the space it travels. Eisenhammer, in 1954,
mentioned that abscess and stula are two stages
of the same condition and therefore coined the
term stulous abscess [40]. The incidence of stula formation after drainage of an abscess ranges
from 15% to 45%. The stula may occur after the
shrinkage of the abscess cavity by spontaneous
rupture or surgical drainage [40].
Perianal abscesses are the commonest and
usually arise from the crypt at the dentate line.
The treatment remains drainage of the abscess.
Primary stulotomy can also be done if the inter-
11.25 Discussion
nal opening can be made out. Eisenhammer preferred partial internal sphincterotomy for draining
The cryptoglandular theory states that stasis in
the ducts obstructs anal glands, leading to infection with abscess or stula formation [7]. Once a
crypt is infected, the infection spreads along the
perianal abscess with curetting of the crypts [40].
Parks preferred partial internal sphincterotomy
with the removal of the infected source [7].
Sometimes only erythema is present in the peri-
178
11 Evaluation andManagement ofAnorectal Abscess
anal region, and the surgeon may treat it conservatively [22]. An abscess will develop invariably
and should be treated accordingly.
An ischiorectal abscess is formed in the central part of the fossa or sometimes may involve
the entire perianal region of the respective side
[7]. It is drained by giving a small radial incision
on the most medial aspect of the abscess, followed by pus evacuation. The abscess is drained
closer to the anal verge so that the subsequent stula if formed, is small.
The intersphincteric abscess may have extensions in the intersphincteric space extending
toward the levators. This is treated by drainage of
the abscess, followed by curetting of the extension, followed by stulotomy at the dentate line.
The supralevator abscesses in 6–8% of the
patients do not cause pain in the anal region. Still,
the patient may complain of chills, heaviness in
the rectum, pyrexia, or urinary retention [28].
One should subject these patients to rectal examination and an MRI.There is a paradigm shift in
draining the supralevator abscess. The abscess
should always be drained by a transanal opening
of an intersphincteric space, followed by a stulotomy at 6 o’clock. Hanley suggested treating
the acute supralevator abscess by complete internal sphincterotomy [28].
The deep postanal space abscess extends anteriorly or to the ischiorectal fossa, forming a
horseshoe abscess. The horseshoe abscesses are
the second commonest abscesses. They are well
managed by opening the deep postanal space.
The deep postanal abscess may extend anteriorly, and the external opening may appear on the
scrotum, labia, perineum, and medial aspect of
the thigh. The patients are treated by drainage of
the deep postanal space and posterior midline
stulotomy. Modied Hanley’s technique
remains the treatment of the choice.
For the anterior deep anal abscess, stulotomy
can be done in males. In females, seton can be
placed, which acts as a drain and converts a complex stula into a simple one [28].
Primary stulotomy with abscess drainage
should be carried out only after assessment of
sphincters. It is never advisable to cut more than
50% of the external anal sphincter. A surgeon
should also be well versed with the technique of
primary sphincter repair to avoid anal
incontinence.
Take-Home Message
• A proper understanding of anatomy is necessary for the surgeon to treat an abscess.
• Preferably, patients with an abscess should be
subjected to imaging for diagnosis.
• An abscess is always managed by incision and
drainage. Giving antibiotics does not make
much sense as the infected pus has to be
drained out.
• Always drain an abscess as close to the anal
verge as possible with a radial or cruciate incision so that subsequent stula formed, if any,
is small. A small incision of 3–4mm is sufcient to drain an abscess. Incision over most
uctuance part of the abscess will lead to large
stula formation.
• No packing is required after abscess drainage.
Insertion of a wick is sufcient to allow the
free drainage of pus.
• Always dilute hydrogen peroxide before injecting it into the tract.
• An ischiorectal abscess may not be associated
with visible signs. The ischiorectal space is
adequate to harbor a large abscess without
any induration. The abscess cavity may
extend posteriorly, leading to a horseshoe
abscess. In such cases, one should do needle
aspiration to conrm the presence of an
abscess. Do not try to break loculi as there are
no loculi but rather the bers of inferior rectal
nerves. Injury to the bers can impair nerve
supply to the external sphincter and cause
paresthesia in the area.
• There is a paradigm shift in treating the supralevator abscess. Irrespective of its origin as an
extension of intersphincteric or transsphincteric abscess, it should always be
drained from the dentate line.
• While probing, always insert the probe from
the internal opening since the chances of for-
References
179
mation of an iatrogenic opening are pretty
high due to inammation.
• Go for minimally invasive procedures. Avoid
creating large raw areas.
References
1. Ansari P.Anorectal abscess. Last full review/revision
Feb 2021. Content last modied Feb 2021. https://www.
msdmanuals.com/en- in/home/digestive- disorders/
anal- and- rectal- disorders/anorectal- abscess.
2. Robinson AM Jr, DeNobile JW. Anorectal
abscess and stula-in-ano. J Natl Med Assoc.
1988;80(11):1209–13.
3. Read DR, Abcarian H. A prospective survey of
474 patients with anorectal abscesses. Dis Colon
Rectum. 1979;22(8):566–8. https://doi.org/10.1007/
BF02587008.
4. Hsieh MH, Lu YA, Kuo G, Chen CY, Sun WC, Lin
Y, et al. Epidemiology and outcomes of anal abscess
patients on chronic dialysis: a 14-year retrospective
study. Clinics. 2019;74:e638.
5. Ramanujam PS, Prasad ML, Abcarian H, Tan
AB.Perianal abscesses and stulas. A study of 1023
patients. Dis Colon Rectum. 1984;27(9):593–7.
https://doi.org/10.1007/BF02553848.
6. Adamo K, Sandblom G, Brännström F, Strigård
K. Prevalence and recurrence rate of perianal
abscess—a population-based study, Sweden 1997–
2009. Int J Color Dis. 2016;31(3):669–73. https://doi.
org/10.1007/s00384- 015- 2500- 7.
7. Parks AG. Pathogenesis and treatment of stulain- ano. Br Med J. 1961;1(5224):463–9. https://doi.
org/10.1136/bmj.1.5224.463.
8. Abcarian H. Relationship of abscess and stula.
In: Abcarian H, editor. Anal stula: principles and
management. New York: Springer. https://doi.
org/10.1007/978- 1- 4614- 9014- 2- 3.
9. Parks AG, Gordon PH, Hardcastle JD.A classication
of stula-in-ano. Br J Surg. 1976;63(1):1–12. https://
doi.org/10.1002/bjs.1800630102.
10. Duhamel J.Anal stulae in childhood. Am J Proctol.
1975;26(6):40–3.
11. Goligher JC, Ellis M, Pissidis AG.A critique of anal
glandular infection in the etiology and treatment
of idiopathic anorectal abscesses and stulas. Br J
Surg. 1967;54(12):977–83. https://doi.org/10.1002/
bjs.1800541202.
12. Brook I.The role of anaerobic bacteria in cutaneous
and soft tissue abscesses and infected cysts. Anaerobe.
2007;13(5–6):171–7.
13. Turner SV, Singh J.Perirectal abscess. In: StatPearls
[Internet]. Treasure Island, FL: StatPearls Publishing;
2022.
14. Whiteford MH.Perianal abscess/stula disease. Clin
Colon Rectal Surg. 2007;20(2):102–9. https://doi.
org/10.1055/s- 2007- 977488.
15. Lunnis PJ. Aspects_of_stula-in-ano. https://discov-
ery.ucl.ac.uk.
16. Hanley PH. Anorectal abscess stula. Surg Clin N
Am. 1978;58(3):487–503.
17. Hamilton CH. Anorectal problems: the deep postanal space—surgical signicance in horseshoe stula
and abscess. Dis Colon Rectum. 1975;18(8):642–5.
https://doi.org/10.1007/BF02604265.
18. Tarasconi A, Perrone G, Davies J, et al. Anorectal
emergencies: WSES-AAST guidelines. World J
Emerg Surg. 2021;16:48. https://doi.org/10.1186/
s13017- 021- 00384- x.
19. Sigmon DF, Emmanuel B, Tuma F.Perianal abscess.
In: StatPearls [Internet]. Treasure Island, FL:
StatPearls Publishing; 2022.
20. Albright JB, Pidala MJ, Cali JR, Snyder MJ,
Voloyiannis T, Bailey HR. MRSA-related perianal
abscesses: an underrecognized disease entity. Dis
Colon Rectum. 2007;50(7):996–1003. https://doi.
org/10.1007/s10350- 007- 0221- x.
21. Eisenhammer S.The anorectal stulous abscess and
stula. Dis Colon Rectum. 1966;9(2):91–106.
22. Ruffo BE.Anorectal abscess, Chapter 13. In: Corman
(eds.) Colorectal surgery; 2015. p.372.
23. Morgan CN.The surgical anatomy of the ischiorectal
space. Proc R Soc Med. 1949;42(3):189–200.
24. Eisenhammer S. The internal anal sphincter; its
surgical importance. S Afr Med J. 1953;27(13):
266–70.
25. Eisenhammer S. The internal anal sphincter and
the anorectal abscess. Surg Gynecol Obstet.
1956;103(4):501–6.
26. Sanyal S, Khan F, Ramachandra P.Successful management of a recurrent supralevator abscess: a case
report. Case Rep Surg. 2012;2012:871639. https://
doi.org/10.1155/2012/871639.
27. Prasad ML, Read DR, Abcarian H. Supralevator
abscess: diagnosis and treatment. Dis Colon Rectum.
1981;24(6):456–61.
28. Hanley PH.Reections on anorectal abscess stula:
1984. Dis Colon Rectum. 1985;28(7):528–33. https://
doi.org/10.1007/BF02554105.
29. Ustynoski K, Rosen L, Stasik J, Riether R, Sheets J,
Khubchandani IT. Horseshoe abscess stula. Seton
treatment. Dis Colon Rectum. 1990;33(7):602–5.
https://doi.org/10.1007/BF02052216.
30. Kinugasa Y, Arakawa T, Abe H, Abe S, Cho BH,
Murakami G, Sugihara K.Anococcygeal raphe revisited: a histological study using mid-term human fetuses
and elderly cadavers. Yonsei Med J. 2012;53(4):849–
55. https://doi.org/10.3349/ymj.2012.53.4.849.
31. Schouten WR, van Vroonhoven TJ.Treatment of anorectal abscess with or without primary stulectomy.
Results of a prospective randomized trial. Dis Colon
Rectum. 1991;34(1):60–3. https://doi.org/10.1007/
BF02050209.
32. Nelson J. Abscess and stula. In: Bailey HR,
Billingham RP, Stamos MJ, Synder MJ, editors.
Colorectal surgery. Philadelphia, PA: Saunders; 2013.
p.133–4.
180
11 Evaluation andManagement ofAnorectal Abscess
33. Scoma JA, Salvati EP, Rubin RJ. Incidence of stulas subsequent to anal abscesses. Dis Colon
Rectum. 1974;17(3):357–9. https://doi.org/10.1007/
BF02586982.
34. Quah HM, Tang CL, Eu KW, Chan SY, Samuel
M.Meta-analysis of randomized clinical trials comparing drainage alone vs. primary sphincter-cutting
procedures for anorectal abscess-stula. Int J Color
Dis. 2006;21(6):602–9. https://doi.org/10.1007/
s00384- 005- 0060- y.
35. Vasilevsky CA, Gordon PH. Benign anorectal:
abscess and stula. In: Wolff BG, Fleshman JW, Beck
DE, etal., editors. The ASCRS textbook of colon and
rectal surgery. NewYork: Springer Science, Business
Media, LLC; 2007. p.192.
36. McElwain JW, MacLean MD, Alexander RM, Hoexter
B, Guthrie JF. Anorectal problems: experience with
primary stulectomy for anorectal abscess, a report
of 1,000 cases. Dis Colon Rectum. 1975;18(8):646–9.
https://doi.org/10.1007/BF02604266.
37. Lockhart-Mummery JP. Fistula in ano. Lancet.
1936;227(5873):657–60.
38. Hebra A, Geibel J. When is stulotomy contraindicated for the treatment of anorectal abscess?
Updated: 24 Jul 2020. AGAF. https://www.medscape.
com/answers/191975- 63735/when- is- fistulotomycontraindicated- for- the- treatment- of- anorectal- abscess.
39. Gupta PJ, Heda PS, Shrirao SA, Kalaskar SS.Topical
sucralfate treatment of anal stulotomy wounds: a randomized placebo-controlled trial. Dis Colon Rectum.
2011;54(6):699–704. https://doi.org/10.1007/
DCR.0b013e31820fcd89.
40. Eisenhammer S. Advance of anorectal surgery with
special reference to ambulatory treatment. S Afr Med
J. 1954;28(13):264–6.