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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1056_Библиотеки_им_академика_М_И_Перельмана.pdf
96 V. de Parades et al.
sometimes difficult and, given the potentially major consequences for the patient,
doctors should not hesitate to seek the support of a more experienced specialist.
Inappropriate incision and injudicious exploration can all too easily convert a simple fistula into
a surgical nightmare, with disastrous consequences for the patient. (Halligan and Stoker 2006)
1 Introduction
Anal cryptoglandular fistula is a disease about which much has been published. This
literature is often contradictory and therapeutic aspects are difficult to analyze given
the many metho dological differences between studies and the infinite variety of
treatments proposed. However, there are a certain number of points for which a
consensus has long been achieved, concerning the clinical evaluation of this disease.
In practice, a clinical evaluation is extremely useful for the following purposes:
• The diagnosis of anal cryptoglandular fistula, and differential diagnosis.
• Topographic evaluations of the principal fistula tract and of possible purulent
collections and/or secondary extensions.
• Evaluations of the anatomy of the anal canal and of the sphincter apparatus.
These diverse elements are essential for the correct management of this disease,
which is challenging to treat due to the need to dry out the suppuration without
exposing the patients to a risk of subsequent anal incontinence (Vogel et al. 2016;
Ommer et al. 2017; Williams et al. 2018; Amato et al. 2020).
2 Types of Clinical Evaluation
Clinical evaluations are mostly performed during consultations (Davies et al. 2008).
However, it may sometimes prove necessary to perform the clinical examination under
anesthesia, if it causes pain and/or if any purulent collection is difficult to reach, high
intersphincteric, deep ischioanal, or supralevatorian (Millan et al. 2006). In any case,
the clinical evaluation requires a thorough understanding of the pathophysiology of
anal fistulae, great rigor, and a habit of practicing this examination (Abou-Zeid 2011).
3 Diagnosis
Anal cryptoglandular fistulae are a precisely defined entity (Table 1), and their
evaluation is, in the vast majority of cases, purely clinical. Indeed, inspection,
palpation of the anal margin and of the perianal region, and digital rectal examination
generally make it possible to identify most fistulae and to ensure correct therapeutic
management without the need for additional imaging examinations.
7 Clinical Assessment of Anal Cryptoglandular Abscess and Fistula 97
Table 1 Clinical criteria defining anal cryptoglandular fistulae
A cryptic endoanal primary opening
A principal fistula tract
One or several secondary openings, possibly with a purulent collection
Possible secondary extensions
Table 2 Principal differential diagnoses for anal cryptoglandular fistula
Infected anal fissure
Cutaneous suppurations (boil, infected sebaceous gland, infected epidermal cyst, etc.)
Crohn’s disease
Hidradenitis suppurativa
Pilonidal disease
Specific infections (tuberculosis, actinomycosis, lymphogranuloma venereum, gonococcosis,
etc.)
Bartholin’s cyst
Ingested foreign body (chicken bone, toothpick, etc.)
Iatrogenic submucous suppurations after instrumental treatment for hemorrhoids or proctological
surgery
Infected subpectineal anal gland
Fisulized vestigial retrorectal cyst
Mucinous colloid cancer
Chronic septic granulomatosis
Diverse causes (osteitis, prostate abscess, prosthetic material, etc.)
However, some suppurations may be misleading (Table 2). A number of differential diagnoses should be considered, notably in cases of the following clinical findings:
• An absence of obvious communication with the anal canal (boil, infected seba-
ceous gland, or pilonidal disease?)
• A subpectineal starting point (infected anal fissure, or infected subpectineal anal
gland?)
• An atypical tract (Crohn’s disease, tuberculosis, or actinomycosis?)
• Presence of cutaneous and/or mucous ulcers of the anus and/or rectum (Crohn’s
disease, tuberculosis, or actinomycosis?)
• Scars and/or other suppurative lesions (hidradenitis suppurativa?)
• But also:
• Risk factors: men who have sex with men (sexually transmitted infections?) or
migrants (tuberculosis?)
• Alteration s of general state and/or bowel movement problems (Crohn’s disease,
or tuberculosis?)
• An inflammatory biological syndrome and/or hyperleukocytosis.
These differential diagnoses are classic traps, and it is important to be vigilant,
because these conditions generally require a different, specific treatment (Hughes
and Mehta 2002).
98 V. de Parades et al.
4 Topographic Evaluation
A simple clinical examination can provide a topographic evaluation of the fistula in
most cases. Such an examination can be used to identify the following elements:
• The cryptic endoanal primary opening.
• The secondary opening or openings.
• The main tract of the fistula.
• Any purulent collections present.
• Any secondary extensions.
However, it is importan t to be aware of a certain number of rules.
4.1 The Cryptic Endoanal Primary Opening
The identification of this opening should be the principal preoccupation of the
operator (Abou-Zeid 2011), and diverse methods may be used to achieve this end
(Table 3). By definition, it is situated in a crypt in the pectinate line.
In the vast majority of cases, there is a single primary opening, but it is not rare for a
fistula to have several secondary openings. In cases of multiple primary openings, there
are usually multiple fistulae, and a specific cause should be sought (Crohn’s disease or
specific infections, such as tuberculosis, actinomycosis, lymphogranuloma venereum,
gonococcus), because such a situation is rare in the cryptoglandular context. Most
primary openings are posterior (at least 75% of cases), but they may , more rarely, be
found in a lateral or anterior position (Parks et al. 1976; Eisenhammer 1978; Atkin et al.
2011). According to Goodsall’s rule (Fig. 1), posterior primary openings are generally
found in a posteromedian position, whereas anterior primary openings are often anterolateral (Goodsall and Miles 1982).
Table 3 Methods for identifying the cryptic endoanal primary opening of an anal cryptoglandular
fistula
Method Aims
Palpation of the fistula tract
Goodsall’s rule
Careful inspection and digital palpation of
the crypts with the tip of the index finger
Injection of air, hydrogen peroxide, or stains
via the secondary opening
Traction of the secondary opening of the
fistula tract with a forceps
Information about the most probable site of the
crypt of origin
Triggering of intense pain
Search for a depression, a zone of inflammation,
the source of pus, and/or an induration
Visualization of the bubbles or stain exiting from
the crypt of origin (quasi-certain method)
Search for invagination of the crypt of origin
7 Clinical Assessment of Anal Cryptoglandular Abscess and Fistula 99
Fig. 1 Goodsall’s rule (PO:
primary opening; SO:
secondary opening)
100 V. de Parades et al.
Fig. 2 Palpation of the fistula
tract at the anal margin.
(Collection Ahlem El
Mituialy)
Identification of the primary opening may be facilitated by palpation of the fistula
tract (Fig. 2) or by careful anoscopic inspection (Fig. 3) and palpation of the
pectinate line (Fig. 4), to check for the emission of pus under pressure, a cryptic
depression that can be catheterized with a probe and/or strong suggestive pain (Atkin
et al. 2011; Abou-Zeid 2011; Jain 2020). A study comparing digital rectal examination and endoscopy showed that these tw o methods had a similar reliability, close to
80% (Choen et al. 1991).
The primary opening can also be identified by “retrograde” catheterization of the
fistula tract, by introducing a probe into the secondary opening. This is generally
performed under anesthesia, because it is necessarily difficult and painful if
performed during consultation. In any case, it is essential not to use force, to avoid
the risk of creating a false primary opening, which would render the fistula complex
and even more difficult to cure.
In the most difficult cases, air (Abou-Zeid 2011), hydrogen peroxide
(Gunawardhana and Deen 2001) or a stain (methylene blue, indigo carmine, etc.)
(de Parades et al. 2010) can be injected into the cutaneous secondary opening
(Fig. 5). If a stain is used, it is important to avoid injecting too much, to prevent
diffuse “staining” of the tissues around the fistula, which would render this technical
artifice ineffective. During surgery, traction of the fistula tract may also be
performed, with a forceps, to invaginate the crypt responsible (Fig. 6) (Eisenhammer
1978; Gonzalez-Ruiz et al. 2006; Kondylis et al. 2009).
7 Clinical Assessment of Anal Cryptoglandular Abscess and Fistula 101
Fig. 3 Inspection of the
pectinate line after the
insertion of a retractor, to
search for the cryptic primary
opening (circle). (Collection
Ahlem El Mituialy)
Fig. 4 Bidigital examination
of the anal canal. (Collection
Ahlem El Mituialy)
102 V. de Parades et al.
Fig. 5 Injection of methylene
blue into the cutaneous
secondary opening.
(Collection Ahlem El
Mituialy)
Fig. 6 Traction of the fistula
tract to invaginate the crypt
responsible (circle).
(Collection Ahlem El
Mituialy)
7 Clinical Assessment of Anal Cryptoglandular Abscess and Fistula 103
That being said, the identification of the primary opening can prove difficult (Sygut
et al. 2010). Indeed, Goodsall’s rule can be wrong in about 5 to 55% of cases,
particularly in cases of anterior fistulae, especially in women, in whom the primary
opening is often median (Cirocco and Reilly 1992; Barwood et al. 1997;Coremans
et al. 2003; Atkin et al. 2011; Cirocco and Reilly 2020), and in cases of posterior
fistulae (Abeysuriya et al. 2010), especially in cases of recurrence (Gunawardhana and
Deen 2001) and/or in cases of trans-sphincteric fistulae rather than intersphincteric
fistulae (Barwood et al. 1997; Jayarajah and Samarasekera 2017). Furthermore, the
injection of a stain into the secondary opening or openings may prove non-informative
in cases of blocked fistula tracts or of large purulent collections, in which the injected
product can accumulate. Finally, it may be impossible to identify the primary opening
in cases of a high fistula tract, particularly if suprasphincteric, in the absence of a
secondary opening, in cases of highly inflammatory abscess-related collections
(Duinslaeger 2000) and/or in patients with a history of multiple proctological surgery
interventions (Gonzalez-Ruiz et al. 2006). It is essential not to be too insistent, and not
to create a false primaryopening, which would make treatmentof the fistula even more
complex (Eisenhammer 1978;Abou-Zeid2011).
4.2 The Secondary Opening or Openings
The secondary openings may be cutaneous (anal margin or skin of the buttocks) or
mucous (rectal wall) in cases of high intersphincteric fistula tract.
Secondary openings at cutaneous sites are variable in appearance. They may be
tiny and difficult to identify, particularly if they are located in the radial folds of the
anal margin (Fig. 7), but they may also be topped by a granuloma that is hypertrophic
and hemorrhagi c on contact, making it possible to detect them immediately (Fig. 8).
In any case, pressure often causes pus to emerge (Fig. 9).
Several ipsilateral secondary openings almost always correspond to the same
primary opening. Bilateral secondary openings should lead to the suspicion of a
contralateral secondary opening in a horseshoe (the most frequent case), Y- or
V-sh aped fistula, or several different fistulae (Parks et al. 1976; Eisenhammer 1978;
Atkin et al. 2011).
4.3 The Main Tract of the Fistula
The fistula tract can often be deduced from the location of the primary opening and any
secondary openings present (Parks et al. 1976;Eisenhammer1978;Marcusetal.
1995; Atkin et al. 2011). Here again, it is important to be aware of certain rules. For
example, the closer a secondary opening is to the anus, the greater the chance of the
fistula tract being located low down, and, conversely, the further it is from the anus, the
greater its chances of being located high up (Becker et al. 2006). When a subcutaneous
cord is palpable at the anal margin, the tract is usually low and, inversely, the absence
of such a palpable cord is suggestive of a high tract (Parks et al. 1976; Eisenhammer
104 V. de Parades et al.
Fig. 7 Small cutaneous
perianal secondary opening
(circle)
Fig. 8 Cutaneous perianal
secondary opening with a
hypertrophic granuloma
(circle)
7 Clinical Assessment of Anal Cryptoglandular Abscess and Fistula 105
1978;Jain2020). According to Goodsall’srule(Fig.1), anterior trans-sphincteric
tracts are mostly directly radial, whereas posterior trans-sphincteric tracts are generally
concave and arciform toward the anterior (Goodsall and Miles 1982; Becker et al.
2006). As a corollary of this law, anterior secondary openings located more than 3 cm
away from the anal margin generally correspond to a long arciform fistula tract with a
posterior cryptic starting point (Goodsall and Miles 1982). The fistula tract should
ideally be identified by bidigital examination of the anal canal, the intersphincteric
space and the perianal spaces (Fig. 4). This identification is then confirmed by
catheterization, with the probe, of the primary opening (Fig. 10). The extremity of
the probe should thus exit via the secondary opening and/or end up in the abscessrelated collection, whence it can be exteriorized via an incision into the skin of the anal
margin (intersphincteric collection), the buttocks (ischioanal collection), or the rectal
mucosa (high intersphincteric collection).
That being said, in certain cases of highly inflammatory abscess-related collections and or fistula tracts that are partly blocked or complex (oblique, bayonetshaped or high), this “anterograde” catheterization may prove particularly laborious,
if not impossible. This is also the case for certain distal intersphincteric tracts and,
above all, for suprasphincteric tracts, for which the chicane corresponding to the
upper intersphincteric part of the fistula tract cannot be catheterized without the use
of force. Attempts can then be made to catheterize the tract via its cutaneous
secondary opening (Fig. 11). In any case, it is important not to use force, to avoid
the creation of an iatrogenic false tract (Eisenhammer 1978; Duinslaeger 2000 ;
Hughes and Mehta 2002; Gonzalez-Ruiz et al. 2006; Holzheimer and Siebeck
2006). Finally, during surgery, the prior injection of a stain generally makes it
possible to delimit the fistula tract and, thus, to facilitate its dissection up to the
point of contact with the sphincter (Gonzalez-Ruiz et al. 2006).
Finally, evaluation of the height of the fistula tract is often feasible, with satisfactory
precision, in consultation. However, this evaluation is more reliable if performed
during surgery, after dissection of the tract. This evaluation is important, because it
directly conditions treatment decisions: immediate fistulotomy, fistulotomy through
several surgical interventions, or the decision to resort to sphincter-saving techniques.
4.4 Possible Purulent Collections
The clinical examination can detect most abscess-related collections. In cases of a
marginal location (the most frequent situation, Fig. 12), or a superficial ischioanal
location (Fig. 13), the abscess-related collection is mostly observed as an inflammatory swelling, often poorly delimited due to a peripheral edematous reaction. Ischioanal purulent collections are generally more voluminous than anal margin purulent
collections, and, what is more, they are often located further away from the anal
opening. By contrast, in cases of high intersphincteric or deep ischioanal purulent
collections, the anal margin initially appears normal and possible signs of inflammation occur late. In this context, digital rectal examination is of the utmost importance.
Spontaneous opening of the anus and/or discharge of pus from the anal orifice should