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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1056_Библиотеки_им_академика_М_И_Перельмана.pdf
230 S. Murad-Regadas and F. S. P. Regadas Filho
Buchanan GN, Bartram CI, Williams AB et al (2005) Value of hydrogen peroxide enhancement of
three-dimensional endoanal ultrasound in fistula-in-ano. Dis Colon Rectum 48:141–147
Caliste X, Nazir S, Goode T et al (2011) Sensitivity of computed tomography in detection of
perirectal abscess. Am Surg 77:166–168
Cavanaugh M, Hyman N, Osler T (2002) Fecal incontinence severity index after fistulotomy: a
predictor of quality of life. Dis Colon Rectum 45:349–353
Cirocco WC, Reilly JC (1992) Challenging the predictive accuracy of Goodsall’s rule for anal
fistulas. Dis Colon Rectum 35:537–542
Davis BR, Kasten KR (2019) Anorectal abscess and fistula. In: Steel RS, Hull TL, Hyman N et al
(eds) The ASCRS manual of colon and rectal surgery, 3rd edn. Springer Nature, Switzerland, pp
179–200
de Souza NM, Gilderdale DJ, Coutts GA (1998) MRI of fistula-in-ano: a comparison of endoanal
coil with external phased array coil techniques. J Comput Assist Tomogr 22:357–363
Garcia-Aguilar J, Belmonte C, Wong WD et al (1996) Anal fistula surgery. Factors associated with
recurrence and incontinence. Dis Colon Rectum 39:723–729
Garcia-Granero A, Granero-Castro P, Frasson M et al (2014) Management of cryptoglandular
supralevator abscesses in the magnetic resonance imaging era: a case series. Int J Color Dis
29:1557–1564
Garg T (2018) Understanding and treating Supralevator Fistula in-ano: MRI analysis of 51 cases
and a review of literature. Dis Colon Rectum 61:612–621
Gold DM, Bartram CI, Halligan S et al (1999) Three-dimensional endoanal sonography in assessing
anal canal injury. Br J Surg 86:365–70
Halligan S, Bartram CI (1998) MR imaging of fistula in ano: are endoanal coils the gold standard?
Am J Roentgenol 171:407–412
Hori M, Oto A, Orrin S et al (2009) Diffusion-weighted MRI: a new tool for the diagnosis of fistula
in ano. J Magn Reson Imaging 30:1021–1026
Hsu Y, Fenner DE, Weadock WJ, DeLancey JO (2005) Magnetic resonance imaging and
3-dimensional analysis of external anal sphincter anatomy. Obstet Gynecol 106(6):1259–1265
Joyce M, Veniero JC, Kiran RP (2008) Magnetic resonance imaging in the management of anal
fistula and anorectal sepsis. Clin Colon Rectal Surg 21:213–219
Kim Y, Park YJ (2009) Three-dimensional endoanal ultrasonographic assessment of an anal fistula
with and without H(2)O(2) enhancement. World J Gastroenterol 15(38):4810–4815
Maconi G, Ardizzone S, Greco S et al (2007) Transperineal ultrasound in the detection of perianal
and rectovaginal fistulae in Crohn’s disease. Am J Gastroenterol 102:2214–2219
Maconi G, Tonolini M, Monteleone M et al (2013) Transperineal perineal ultrasound versus
magnetic resonance imaging in the assessment of perianal Crohn’s disease. Inflamm Bowel
Dis 19:2737–2743
Morren GL, Beets-Tan RG, van Engelshoven JM (2001) Anatomy of the anal canal and perianal
structures as defined by phased-array magnetic resonance imaging. Br J Surg 88(11):1506
Murad-Regadas SM, Regadas FSP (2008) Two- and three- dimensional ultrasonography in abscess
and anal fistula. In: Pescatori M, Regadas FSP, Murad-Regadas SM, Zbar AP (eds) Imaging
atlas of the pelvic floor and anorectal diseases. Springer, Milan, pp 51–62
Murad-Regadas SM, Regadas FSP, Rodrigues LV et al (2010) Role of three-dimensional anorectal
ultrasonography in the assessment of anterior transsphincteric fistula. Dis Colon Rectum 53:
1035–1040
Murad-Regadas SM, Regadas FSP, Rodrigues LV et al (2011) Anatomic characteristics of anal
fistula on three-dimensional anorectal ultrasonography. Dis Colon Rectum 54:460–466
Murad-Regadas SM, Dealcanfreitas ID, de Oliveira MTCC et al (2015) Anatomical characteristics
of anal fistula evaluated by three-imensional anorectal ultrasonography: is there a correlation
with Goodsall’s theory? J. Coloproctology 35:83–89
Nagendranath C, Saravanan MN, Sridhar C, Varughese M (2014) Peroxide-enhanced endoanal
ultrasound in preoperative assessment of complex fistula-in-ano. Techniques in Coloproctology
18(5):433–438
–1512
14 Future Perspectives in the Diagnosis of Anal Fistula and Abscess 231
Ortega AE, Bubbers E, Liu W et al (2015) A novel classification, evaluation, and treatment strategy
for supralevator abscesses. Dis Colon Rectum 58:1109–1110
Ortega AE, Cologne KG, Shin J et al (2017) Treatment based three-dimensional classification and
management of anorectal infections. World J Surg 41:574–589
Parks AG (1961) Pathogenesis and treatment of fistula-in-ano. Br Med J 1:463–469
Ratto C, Grillo E, Parello A et al (2005) Endoanal ultrasound-guided surgery for anal fistula.
Endoscopy 37:722–728
Regadas FSP, Murad-Regadas SM, Lima DM et al (2007) Anal canal anatomy showed by three-
dimensional anorectal ultrasonography. Surg Endosc 21:2207–2211
Sangwan YP, Rosen L, Riether RD et al (1994) Is simple fistula-in-ano simple? Dis Colon Rectum
37:885–889
Schwartz DA, Loftus EV Jr, Tremaine WJ et al (2002) The natural history of fistulizing Crohn’s
disease in Olmsted County, Minnesota. Gastroenterology 22:875–880
Siddiqui MR, Ashrafian H, Tozer P et al (2012) A diagnostic accuracy meta-analysis of endoanal
ultrasound and MRI for perianal fistula assessment. Dis Colon Rectum 55(5):576–585
Steele SR, Kumar R, Feingold D et al (2011) Practice parameters for the treatment of perianal
abcess and fistula-in-ano. Dis Colon Rectum 54:1465–1474
Sygut A, Mik M, Trzcinski R, Dziki A (2010) How the the location of the internal opening of anal
fistulas affect the treatment results of primary transsphincteric fistulas. Langenbecks Arch Surg
395(8):1055–1059
Tabry H, Farrands PA (2011) Update on anal fistulae: surgical perspectives for the gastroenterol-
ogist. Can J Gastroenterol 25(12):675–680
West RL, Dwarkasing S, Felt-Bersma RJ et al (2004) Hydrogen peroxide-enhanced three-dimen-
sional endoanal ultrasonography and endoanal magnetic resonance imaging in evaluating
perianal fistulas: agreement and patient preference. Eur J Gastroenterol Hepatol 16:1319–1324
Williams AB, Bartram CI, Halligan S et al (2001) Multiplanar anal endosonography – normal anal
canal anatomy. Color Dis 3:169–174
Zimmerman DDE, Briel JW, Gosselink MP, Schouten WR (2001) Anocutaneous advancement flap
repair of transsphincteric fistulas. Dis Colon Rectum 44:1474–1480
Part IV
Treatment of Cryptoglandular Fistula/Abscess
How to Drain an Abscess
15
Michel Adamina and Gioia Pozza
Contents
1 Introduction .................... ............................... ............................. 236
2 Epidemiology and Etiology ......................... ....................................... 236
3 Classification ............................. .................................................. 237
4 Clinical Manifestations and Diagnosis ... ................................................. 239
5 Management ................................................................................ 239
6 Management of a Fistula Encountered When Draining an Abscess . ...... . . . . ....... . . . . 243
7 Wound Dressing ............................................................................ 245
8 Microbiology and Antibiotics ............................................................. 246
9 General Postoperative Management ......................... .............................. 246
10 Conclusion .................... ................................. ............................ 246
11 Cross-References .......... ................................................................. 247
References ............................ ............................................... ............ 247
Abstract
Anorectal abscesses belong to the most frequent emergency worldwide with an
estimated 500,000 new anorectal abscesses in Europe and North America, which
is roughly similar to the number of appendectomy performed in these countries. It
may affect anybody and originate mostly from obstructed cryptoglandular tissue.
Fistula complicates about 25–50% of abscess, while life-threatening sepsis
remains exceptional. Swift diagnosis and treatment are important to avoid
unneeded suffering and depend on history taking and clinical examination,
followed by a prompt drainage procedure. The Park’s classification is useful to
document and guide therapy. Adequate surgical drainage and debridement are
M. Adamina (*)
Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
Faculty of Medicine, University of Basel, Basel, Switzerland
G. Pozza
Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
Department of Surgery, University of Trieste, Trieste, Italy
© Springer Nature Switzerland AG 2022
C. Ratto et al. (eds.), Anal Fistula and Abscess, Coloproctology,
https://doi.org/10.1007/978-3-030-76670-2_17
235
236 M. Adamina and G. Pozza
paramount, considering that almost half of anorectal abscesses relapse within
1 year of drainage. Most anorectal abscess can be drained and debrided with a
single radial incision in an outpatient setting. A fistula is frequently found either at
diagnosis or during early follow-up: It can be drained with a seton and referred to
specialized treatment once inflammation has subsided or left alone as many will
heal spontaneously. Routine management of postoperative care is important as
secondary wound healing is the rule. Wound cleaning thrice daily with tap water
is enough, and antibiotics postdrainage are rarely required. Last but not least,
thorough information and counseling of the patient are required to optimize
perioperative compliance and outcome.
Keywords
Abscess · Drainage · Perianal · Proctology · Fistula · Anal abscess · Anal fistula
1 Introduction
Anorectal abscesses are non-life-threatening yet highly bothering conditions and
among the leading causes of proctological emergencies worldwide. Their management includes prompt clinical evaluation and surgical drainage as the gold standard.
Clinical presentation varies widely, ranging from small purulent subcutaneous
collection to complex chronic fistulizing disease.
This chapter aims to be a practical and straight forward guide, especially for
young surgeons who need to be prepared to evaluate, classify, and treat this spectrum
of diseases.
2 Epidemiology and Etiology
Estimated figures of at least 300,000 new anorectal abscesses annually in Europe and
200,000 in North America are reasonable, yet exact numbers are difficult to determine as medical attention is not always sought and treatment takes place in a large
variety of settings (Abcarian 2011; Zanotti et al. 2007). Anorectal abscesses occur
more frequently in males than in females (2:1 to 5:1) (Sainio 1984), with a peak of
incidence in patients 20–50 years old (Nelson et al. 1995 ). Up to 90% of anal
abscesses originate from the obstruction and infection of anal cryptoglandular tissue.
Spontaneous drainage may occur through the anal mucosa, or expansion and
drainage may happen through the intersphincteric or transsphincteric route. There
are 8–10 anal crypt glands which arise from the dentate line with individual variation
in number and location (Seow-Choen and Ho 1994). Males usually have more crypt
glands than females, while most glands tend to be located posteriorly – and so do
also abscesses and fistula-in-ano (Abeysuriya et al. 2010). Anal abscess and fistula
15 How to Drain an Abscess 237
represent different stages of the same disease, whereas fistulas result from a chronic
infection that leads to the epithelialization of an abscess drainage tract, including at
times the development of secondary anorectal abscesses (Cox et al. 1997;
Eisenhammer 1956; Gosselink et al. 2015; Parks 1961). Fistulas, found either at
initial presentation or during follow-up, complicate about 25–50% of anorectal
abscesses for an incidence of about 3/10,000 in Europe or up to 150,000 new fistulas
a year (Abcarian 2011).
There are no convincing data to blame lack of hygiene, altered bowe l habits, anal
intercourse, obesity, or diabetes as risk factors for anorectal abscess. Conversely,
inflammatory bowel diseases, in particular anorectal Crohn’s disease, are a risk
factor for the occurrence and severity of anorectal abscess. Smoking, diabetes,
sexually transmitted diseases, prior anorectal surgery or trauma, regional radiation
therapy, immunodepressive states, and inflammatory bowel diseases are associated
with more severe course of disease (Goligher et al. 1967; Marks et al. 1981; Culp
1983; Adamo et al. 2016; Wei et al. 2013; Devaraj et al. 2011; Baker et al. 2014;
Chen et al. 2013). Microbiological analysis mostly reveals typical lower gastrointestinal aerobic and anaerobic pathogens, i.e., E. Coli and Bacteroides mixed with
skin germs such as S. Aureus (Toyonaga et al. 2007).
3 Classification
An anal abscess is classified based upon the potential space it has spread into,
respectively on the relation to the surrounding anatomical structures. Superficial
abscesses (perianal, ischiorectal) occur most frequently, followed by intersphincteric
abscesses, while supralevator abscesses are the least common. Some suggest
intersphincteric abscess as the most frequent initial presentation, from where spread
can occur downward to the perianal region, laterally through the external anal
sphincter, or upward crossing the levator ani muscle.
The Park’s class ification of anorectal abscesses includes 5 types of abscesses
(Fig. 1) (Parks et al. 1976):
1. Perianal or Subdermal
2. Perirectal: Among them, it is possible to distinguish between:
(a) Submucosal
(b) Intersphincteric
(c) Ischiorectal or transsphincteric
(d) Supralevator
A particular type of perirectal abscess is the horseshoe abscess (Held et al. 1986).
This complex abscess originates posteriorly from the deep postanal space. The deep
postanal space is a potential space bound by the levator plates superiorly, the coccyx
and anococcygeal ligament inferiorly and posteriorly, and the external anal sphincter
238 M. Adamina and G. Pozza
5
2
3
4
1
Fig. 1 Five types of perianal abscesses according to Parks: (Abcarian 2011) superficial/sub-
dermal; (Zanotti et al. 2007 ) submucosal; (Sainio 1984) intersphincteric; (Nelson et al. 1995)
ischiorectal; and (Seow-Choen and Ho 1994) supralevator. Possible routes of spread from the
submucosal and intersphincteric origin in red
Fig. 2 Horseshoe abscess.A
horseshoe abscess extends
into both ischioanal fossae out
of the deep postanal space
anteriorly. Pus can accumulate into the deep postanal space and spread bilaterally
through the intersphincteric, ischiorectal/transsphincteric, and rarely supralevator
routes (Fig. 2). This process creates a horseshoe-shaped a bscess into both
ischioanal fossae.
15 How to Drain an Abscess 239
4 Clinical Manifestations and Diagnosis
The most common presentation is acute onset of severe pain in the perianal/
perirectal region, frequently associated with a locoregional bulging. The pain is
constant and worsens when sitting and defecating. Fever, leukocytosis, and elevated c-reactive protein level are common findings. Perianal drainage of purulent
fluid may be present at the time of diagnosis if the abscess had already drained
spontaneously. Spontaneous drainage is generally accompanied by a relief of the
acute pain (Sahnan et al. 2017). When taking the patient’s history, documentation
of bowel habits and especially continence prior to treatment and abscess formation
is mandatory in order to properly assess function. Many validated scoring systems
therefor exist, e.g., the Vaizey/St. Marks i ncontinence score (Vaizey et al. 1999). At
physical examination, classic signs include painful erythema, induration, fluct ua tion, and spontaneous drainage for most abscesses. Conversely, intersphincteric
and supralevator abscesses bear little external signs. Gentle digital rectal exam
and/or proctoscopy, if possible at all, may reveal a painful submucosal fluctuation
andaninternalorifice while excluding an anal fissure. In a typical clinical
presentation, a prompt exam under anesthesia may allow for diagnosis and treatment at the same time. When suspecting an intersphincteric abscess, percutaneous
needle aspiration from the intersphincteric groove (also known as anocutaneous
line or Hilton line) may allow for exact localization of the abscess (Hyman 1999;
Nelson 2002;Rosen1994).
Imaging studies can be requested when a deep abscess is suspected or in presence
of a complex abscess-fistula disease. Computed tomography is nowadays readily
available in the emergency setting, yet its diagnostic yield ranges from 70% to 77%
(Caliste et al. 2011). Magnetic resonance imaging (MRI) and endosonography
(EUS) are the most accurate techniques for both correct localization of the abscess
and identification of fistula tracts with a sensitivity of 87% (MRI and EUS) and a
specificity of 69% and 43%, respectively (Siddiqui et al. 2012). A thorough EUS
requires anesthesia when performed for an acute abscess, whereas transperineal
ultrasound (TPUS) can be performed bedside, with sensitivity similar to EUS in
detecting perianal abscess and a sensitivity of 85% for anal fistula (Maconi et al.
2013). Last, fistulography, which consists of the injection of a dye (or hydrogen
peroxyde for EUS fistulography) through the fistula’s external opening, is useful for
identifying the correct anatomy of complex multibranched fistula tracts to better plan
the surgical treatment (Pomerri et al. 2010). As for all medical interventions, the
accuracy of imaging and diagnostic techni ques is as good as the experience and
skills of the people requesting and reading it.
5 Management
The treatment of an anorectal abscess is early surgical drainage (grade of recommendation: 1C) (Vogel et al. 2016). Conservative management with antimicrobial
agents cannot be recommended in uncomplicated anorectal abscess (grade of
240 M. Adamina and G. Pozza
recommendation: 1B) (Amato et al. 2015), as it delays adequate treatment and
increases the chances of potential life-threatening conditions such as sepsis, necrotizing fasciitis, and long-term pelvic function impairment.
Timing of surgery is decided on clinical grounds. Spontaneous drainage warrants surgical completion of drainage. Any undrained or i ncompletely drained
abscess has a high probability to persist, relapse, or evolve into a chronic fistula
or generalized sepsis.
Considering that almost 44% of anorectal abscesses relapse within 1 year after
drainage (Cox et al. 1997; Vasilevsky and Gordon 1984; Yano et al. 2010), there are
three key points to remember for a safe and sufficient drainage:
1. Accurate localization of the abscess.
2. Complete debridement of the cavity: Any loculation has to be disrupted by digital
or instrumental curettage.
3. Careful examination of the anal canal looking for fistula.
To achieve these three points, adequate analgesia and ideally relaxation of the
anal sphincter are required.
Surgical drainage is tailored according to the abscess at hand. Most anorectal
abscess can be drained in an outpatient setting and frequently in local anesthesia, and
pending truly adequate surgical expertise is available. Otherwise, general anesthesia
and inpatient care are preferred to allow for complete drainage and sound postoperative care (Fig. 6).
• Perianal and Ischiorectal/Transsphincteric
Drainage is recommended through a linear and radial incision of the perianal
skin. In order to minimize the length of a potential fistula, this incision has to be
made as close to the anal verge as possible, yet outside of the sphincter (Vogel
et al. 2016; Amato et al. 2015) (Fig. 3). The length of the incision, as a rule,
should be equal to the depth of the abscess or larger. Cruciate incision and cutout
excision are useless as they do not provide a better drainage than a radial incision
but end in a considerable loss of perianal tissue.
• Submucosal and Intersphincteric
These types of abscesses should be drained into the rectum through a mucosal
or at least through a transluminal partial internal sphincterotomy (Millan et al.
2006) (Fig. 4). Rectoscopy allows for direct visualization and localization of the
abscess. When feasible, an incision is recommended below the dentate line
through the anal mucosa. The incision edges may be sutured for hemostatic
purposes, but the cavity has to be left open.
• Supralevator
Supralevator abscesses are drained either through the rectal wall and into its
lumen or percutaneously, depending on the etiology. EUS and MRI (preferred for
this purpose as it allows a thorough evaluation of the pelvis) can assess the
integrity of the levator ani and origin of the supralevator abscess.
A transanal or transrectal drainage is required to prevent formation of an
extrasphincteric fistula when the levator ani muscles are intact and the
15 How to Drain an Abscess 241
Fig. 3 Drainage of a
perianal abscess. Drainage is
performed by a linear and
radial incision of the perianal
skin, whose length equates the
depth of the abscess. Cruciate
incision or cut out excision is
useless and should not be
performed
supralevator abscess is originating from either a pelvic inflammatory disease
(e.g., diverticulitis) or from an upward extension out of an intersphincteric
abscess (Fig. 5a).
Conversely, when the levator an i have been disrupted and the supralevator
abscess results from an upward extension of a transsphincteric/ischiorectal
abscess, a percutaneous approach is considered (Prasad et al. 1981) (Fig. 5b).
In presence of an extensive or complex abscess disease, the insertion of a drain
and/or repeat surgical exploration and thorough lavage after few days can complement the initial surgical drainage.
• Special Cases
– Horseshoe Abscesses
Horseshoe abscesses are generally drained with a posterior radial incision
midway from the anal verge and coccyx and additional counterincisions on
one or both sides of the anus. A surgical drain (e.g., an easy flow) can be
inserted between the external incisions. Large semicircular posterior incision
should be avoided because they heal slower than radial ones and provide no
additional benefit. When the internal opening of a fistula is identified, a
modified Hanley technique is advisable. It consists of a partial distal
sphincterotomy associated with a midline seton and bilateral radial incisions
over the ischiorectal fossae (Browder et al. 2009). More recently, a one-stage