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242 M. Adamina and G. Pozza
Fig. 4 Drainage of a
submucosal or
intersphincteric abscess.
Drainage is performed
through the anorectal lumen
by an intersphincteric incision
below the dentate line
Fig. 5 Drainage of a supralevator abscess. A transrectal drainage (a) is performed when the
levator plate is intact and the supralevator abscess originates from a pelvic source or from an upward
abscess extension along the intersphincteric space. Conversely, a percutaneous drainage (b)is
performed when the levator ani have been disrupted or the supralevator abscess results from an
upward extension of a transsphincteric/ischiorectal abscess
15 How to Drain an Abscess 243
approach has been proposed which replaces the seton drainage by a ligation of
the intersphincteric fistula tract supplemented by adequate bilateral incisions
and drainage (Tan et al. 2013).
– Recurrent Abscesses
Recurrence rate is up to 44% after initial surgical drainage of an anorectal
abscess. Risk factors for recurrence are the following:
Inadequate surgical drainage and insufficient postoperative care.
Missed secondary abscesses.
Horseshoe abscesses.
Failure to manage a primary fistula: This latter point is, however, a contro-
versial issue. An untreated primary fistula has about a 50% chance to heal
spontaneously versus none to heal whenever a seton is placed. Also,
complex fistula procedures beyond simple fistulotomy are contraindicated
when local sepsis is present.
– Crohn’s Disease
Crohn patients harboring perianal abscess are prone to a complicated
course, including multiple abscesses, complex fistula, and multiple recurrences. Local sepsis control does not differ from cryptoglandular abscess and
requires adequate surgical drainage with a radial incision. Yet, search for a
fistula and insertion of a seton drainage are mandatory whenever an internal
fistula opening is identified (Adamina et al. 2020 ). Attention should be paid
not to injure the sphincter, neither surgically or by inconsiderate anal dilation
in presence of scarring and/or insufficient anesthesiological sphincter relaxation. Once surgical drainage has been performed, intensified medical treatment
is paramount in order to control Crohn proctitis and allow for healing of the
abscess-fistula, respectively removal of the seton. Pelvic MRI should be
liberally performed to assess and follow the course and complexity of perianal
Crohn’s disease.
When multiple subcutaneous abscesses are present, acne inversa may be the
primary cause of the perianal abscesses and mandate another approach than mere
surgical drainage.
An alternative approach to classical surgical drainage is the percutaneous or
transanal placement of a small drainage catheter into the abscess cavity to be kept
in place until the drainage stops (Beck et al. 1988). This approach does not allow for
exploration and digital disruption of any loculation, yet it has shown some success,
in particular in the pediatric literature (Ladd et al. 2010; Alder et al. 2011).
6 Management of a Fistula Encountered When Draining
an Abscess
A fistula is a tract that connects the perineal skin to the anorectal lumen. It is found in
30–70% of patients with anorectal abscesses at the time of diagnosis (Cox et al.
1997; Parks 1961; Vasilevsky and Gordon 1984). When a fistula is not found during
244 M. Adamina and G. Pozza
Fig. 6 How to drain an
abscess. The incision is
centered on the area of
maximal fluctuation upon
clinical evaluation. A linear
and radial incision is
performed through the
perianal skin, and pus is
allowed to drain. The incision
length equates the abscess
size. Digital exploration
followed by lavage ensures
disruption of any loculation
and thorough drainage. The
linear incision stays open by
virtue of tensile forces of the
buttocks. Showering the
wound three times a day and
after every bowel movement
ensures secondary wound
healing within few weeks
15 How to Drain an Abscess 245
abscess drainage, it will develop in about 25–50% of patients months to years later
(Zanotti et al. 2007; Hamalainen and Sainio 1998). A fistula is suspected whenever
an incised abscess fails to heal over few weeks and/or intermittent pain and secretion
of pus is noted.
The internal fistula opening is identified at rectoscopy mostly as a tiny inflamed
area. Application of pressure on the abscess cavity may help and deliver pus out of
the internal fistula opening, as can fistula irrigation with a blue dye and/or hydrogen
peroxyde from the outside opening, respectively skin incision. Hydrogen peroxyde
also helps identification of the fistula tract by endosonography.
The type of primary abscess influences the likelihood of finding a fistula.
Subdermal abscesses are rarely associated with a fistula,andwhenafistula is
found, it is usually a superficial simple submucosal or intersphincteric fistul a
amenable to fistulotomy. Complex fistulas involving significant amount of the
anal sphincter follow the abscess typology, e.g., a transsphincteric fistula out of a
transsphincteric abscess. In the context of an emergency abscess drainage, concomitant fistulotomy/fistulectomy may be considered for simple anal fistula, e.g.,
in a submucosal fistula (Grade of recommendation: 2B) (Vogel et al. 2016). A
fistulotomy or a fistulectomy performed during abscess drainage decreases the risk
of persistence/recurrence of the abscess (relative risk: 0.13, 95% CI 0.07–0.24), yet
it also markedly increases the risk of a clinically relevant sphincter injury (relative
risk 3.06, 95% CI 0.7– 13.45) (Malik et al. 2010). Complex fistula repair performed
at the initial drainage procedure has little prospect of success owing to the inflamed
surgical field. Hence, when a fistula is identified during abscess drainage, the
surgeon has 2 options:
– Leave the fistula as it is and hope for spontaneous obliteration and healing of the
abscess-fi
– Place a seton drainage and differ fistula treatment for 2 months or more to allow
for sepsis resolution
stula
7 Wound Dressing
Once an abscess has been adequately drained, primary wound closure is prohibited
and secondary wound healing is pursued. Light packing of the drained abscess cavity
follows lavage and hemostasis. Of note, tight packing of an incision beyond the
initial postoperative dressing is increasing pain and slowing down wound healing
(O’Malley et al. 2009; Perera et al. 2015; Tonkin et al. 2004).
Secondary wound healing requires regular wound cleaning, i.e., selfshowering or assisted i rrigation three times a day and after ev ery bowel mov ement using tap water. Wound dressing has as the only purpose to protect the
surroundings from the wound secre tions. Hence, sanitary pads offer an inexpensive option which perfectly matches the dressing needs of a patient with a d rained
anorectal abscess.
246 M. Adamina and G. Pozza
8 Microbiology and Antibiotics
A routine intraoperative swab is not usually indicated (Grade of recommendation:
2C) (Vogel et al. 2016), unless fulminant sepsis is present or a fasciitis is suspected,
which then requires histology and prompt, large debridemen t. Antibiotics are not
given to otherwise healthy patients as they have no effect in reducing recurrence rate
or improving healing.
An intraoperative swab and antibiotic treatment are reserved for patients
presenting with:
1. Systemic sepsis
2. Locoregional cellulitis or large phlegmon
3. HIV infec tion
4. Prosthetic heart valve
5. Previous bacterial endocarditis
6. Congenital heart disease
7. Organ transplant recipient
Antibiotics are also recommended when a methicillin-resistant Staphylococcus
aureus is suspected/isolated.
9 General Postoperative Management
Once an abscess is surgically drained, pain relief follows immedi ately. In addition, a
perianal block is advised, e.g., 20 ml of bupivacaine 0.25% injected into the
intersphincteric plane at 3 h and 9 h in lithotomy position. Paracetamol and metamizole per os and liberal use of stool softener, e.g., macrogol 3350 and liquid
paraffin, have proven helpful in maintaining pain control. Secondary wound healing
is usually a matter of few weeks, including repeat daily wound irrigation. Once to
twice weekly office visits are advisable during early recovery to check upon the
patient. Most of the time, a patient can return to work within 10–14 days following
abscess drainage, and pending continued wound care/lavage is ensured. Last but not
least, thoro ugh information and counseling of the patient are required to optimize
compliance and outcome.
10 Conclusion
Anorectal abscesses are as frequent as appendicitis. Properly managing them
requires typical surgical qualities: swift diagnosis based on good history taking
and clinical examination; prompt treatment without time wasted with fancy additional examinations, but for the few situations where clinical experience leads to a
suspicion of complexity, e.g., Crohn’s disease; thorough drainage and debridement
guided by knowledge of the anatomy and of the disease at hand, with a simple radial
15 How to Drain an Abscess 247
incision sufficient most of the time; and thorough information and counseling of the
individual patient prior to and following surgery. It is hoped that the present chapter
will contribute to developing the theoretical framework and practical knowledge
required to perform sound diagnosis and treatment of anorectal abscesses.
11 Cross-References
▶ Anorectal Anatomy Related to Anal Fistula and Abscess
▶ Anorectal Physio logy Related to Anal Fistula and Abscess
▶ Classification of Anal Fistula and Abscess
▶ Clinical Assessment of Anal Cryptoglandular Abscess and Fistula
▶ Clinical Assessment of Crohn Perianal Abscesses and Fistulas
▶ Epidemiology of Anal Fistula and Abscess
▶ Endoanal Ultrasound in the Diagnosis of Cryptoglandular Anal Fistulas and
Abscesses
▶ Evidences for Optimal Surgical Management of Anal Fistulas and Abscesses
▶ From Abscess to Fistula
▶ Magnetic Resonance and Traditional Radiology in the Diagnosis of
Cryptoglandular Anal Fistula and Abscess
▶ Ostomy and Proctectomy to Treat Anal Fistulas and Abscess; When and Why
▶ Utility and Limitations of Endoanal Ultrasound in the Diagnosis of Crohn’s Anal
Fistula and Abscess
References
Abcarian H (2011) Anorectal infection: abscess-fistula. Clin Colon Rectal Surg 24(1):14–21
Abeysuriya V, Salgado LS, Samarasekera DN (2010) The distribution of the anal glands and the
variable regional occurrence of fistula-in-ano: is there a relationship? Tech Coloproctol 14(4):
317–321
Adamina M, Bonovas S, Raine T, Spinelli A, Warusavitarne J, Armuzzi A, Bachmann O, Bager P,
Biancone L, Bokemeyer B, Bossuyt P, Burisch J, Collins P, Doherty G, El-Hussuna A, Ellul P,
Fiorino G, Frei-Lanter C, Furfaro F, Gingert C, Gionchetti P, Gisbert JP, Gomollon F, González
Lorenzo M, Gordon H, Hlavaty T, Juillerat P, Katsanos K, Kopylov U, Krustins E, Kucharzik T,
Lytras T, Maaser C, Magro F, Marshall JK, Myrelid P, Pellino G, Rosa I, Sabino J, Savarino E,
Stassen L, Torres J, Uzzan M, Vavricka S, Verstockt B, Zmora O (2020) ECCO guidelines on
therapeutics in Crohn’s Disease: surgical treatment. J Crohns Colitis 14(2):155–168
Adamo K, Sandblom G, Brannstrom F, Strigard K (2016) Prevalence and recurrence rate of perianal
abscess--a population-based study, Sweden 1997–2009. Int J Color Dis 31(3):669–673
Alder AC, Thornton J, McHard K, Buckins L, Barber R, Skinner MA (2011) A comparison of
traditional incision and drainage versus catheter drainage of soft tissue abscesses in children. J
Pediatr Surg 46(10):1942–1947
Amato A, Bottini C, De Nardi P, Giamundo P, Lauretta A, Realis Luc A, Tegon G, Nicholls RJ
(2015) Italian society of colorectal s. evaluation and management of perianal abscess and anal
fistula: a consensus statement developed by the Italian Society of Colorectal Surgery (SICCR).
Tech Coloproctol 19(10):595–606
248 M. Adamina and G. Pozza
Baker B, Al-Salman M, Daoud F (2014) Management of acute perianal sepsis in neutropenic
patients with hematological malignancy. Tech Coloproctol 18(4):327–333
Beck DE, Fazio VW, Lavery IC, Jagelman DG, Weakley FL (1988) Catheter drainage of
ischiorectal abscesses. South Med J 81(4):444–446
Browder LK, Sweet S, Kaiser AM (2009) Modified Hanley procedure for management of complex
horseshoe fistulae. Tech Coloproctol 13(4):301–306
Caliste X, Nazir S, Goode T, Street JH 3rd, Hockstein M, McArthur K, Trankiem CT, Sava JA
(2011) Sensitivity of computed tomography in detection of perirectal abscess. Am Surg 77(2):
166–168
Chen CY, Cheng A, Huang SY, Sheng WH, Liu JH, Ko BS, Yao M, Chou WC, Lin HC, Chen YC,
Tsay W, Tang JL, Chang SC, Tien HF (2013) Clinical and microbiological characteristics of
perianal infections in adult patients with acute leukemia. PLoS One 8(4):e60624
Cox SW, Senagore AJ, Luchtefeld MA, Mazier WP (1997) Outcome after incision and drainage
with fistulotomy for ischiorectal abscess. Am Surg 63(8):686–689
Culp CE (1983) Chronic hidradenitis suppurativa of the anal canal. A surgical skin disease. Dis
Colon Rectum 26(10):669–676
Devaraj B, Khabassi S, Cosman BC (2011) Recent smoking is a risk factor for anal abscess and
fistula. Dis Colon Rectum 54(6):681–685
Eisenhammer S (1956) The internal anal sphincter and the anorectal abscess. Surg Gynecol Obstet
103(4):501–506
Goligher JC, Ellis M, Pissidis AG (1967) A critique of anal glandular infection in the aetiology and
treatment of idiopathic anorectal abscesses and fistulas. Br J Surg 54(12):977–983
Gosselink MP, van Onkelen RS, Schouten WR (2015) The cryptoglandular theory revisited. Color
Dis 17(12):1041–1043
Hamalainen KP, Sainio AP (1998) Incidence of fistulas after drainage of acute anorectal abscesses.
Dis Colon Rectum 41(11):1357–1361. discussion 1361-1352
Held D, Khubchandani I, Sheets J, Stasik J, Rosen L, Riether R (1986) Management of anorectal
horseshoe abscess and fistula. Dis Colon Rectum 29(12):793–797
Hyman N (1999) Anorectal abscess and fistula. Prim Care 26(1):69–80
Ladd AP, Levy MS, Quilty J (2010) Minimally invasive technique in treatment of complex,
subcutaneous abscesses in children. J Pediatr Surg 45(7):1562–1566
Maconi G, Tonolini M, Monteleone M, Bezzio C, Furfaro F, Villa C, Campari A, Dell’Era A,
Sampietro G, Ardizzone S, de Franchis R (2013) Transperineal perineal ultrasound versus
magnetic resonance imaging in the assessment of perianal Crohn’s disease. Inflamm Bowel
Dis 19(13):2737–2743
Malik AI, Nelson RL, Tou S (2010) Incision and drainage of perianal abscess with or without
treatment of anal fistula. Cochrane Database Syst Rev 7:CD006827
Marks CG, Ritchie JK, Lockhart-Mummery HE (1981) Anal fistulas in Crohn’s disease. Br J Surg
68(8):525–527
Millan M, Garcia-Granero E, Esclapez P, Flor-Lorente B, Espi A, Lledo S (2006) Management of
intersphincteric abscesses. Color Dis 8(9):777–
Nelson R (2002) Anorectal abscess fistula: what do we know? Surg Clin North Am 82(6):
1139–1151
Nelson RL, Abcarian H, Davis FG, Persky V (1995) Prevalence of benign anorectal disease in a
randomly selected population. Dis Colon Rectum 38(4):341–344
O’Malley GF, Dominici P, Giraldo P, Aguilera E, Verma M, Lares C, Burger P, Williams E (2009)
Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad
Emerg Med 16(5):470–473
Parks AG (1961) Pathogenesis and treatment of fistuila-in-ano. Br Med J 1(5224):463–469
Parks AG, Gordon PH, Hardcastle JD (1976) A classification of fistula-in-ano. Br J Surg 63(1):1–12
Perera AP, Howell AM, Sodergren MH, Farne H, Darzi A, Purkayastha S, Paraskeva P (2015) A
pilot randomised controlled trial evaluating postoperative packing of the perianal abscess.
Langenbeck’s Arch Surg 400(2):267–271
780
15 How to Drain an Abscess 249
Pomerri F, Dodi G, Pintacuda G, Amadio L, Muzzio PC (2010) Anal endosonography and
fistulography for fistula-in-ano. Radiol Med 115(5):771–783
Prasad ML, Read DR, Abcarian H (1981) Supralevator abscess: diagnosis and treatment. Dis Colon
Rectum 24(6):456–461
Rosen L (1994) Anorectal abscess-fistulae. Surg Clin North Am 74(6):1293–1308
Sahnan K, Adegbola SO, Tozer PJ, Watfah J, Phillips RK (2017) Perianal abscess. BMJ 356:j475
Sainio P (1984) Fistula-in-ano in a defined population. Incidence and epidemiological aspects. Ann
Chir Gynaecol 73(4):219–224
Seow-Choen F, Ho JM (1994) Histoanatomy of anal glands. Dis Colon Rectum 37(12):1215–1218
Siddiqui MR, Ashrafian H, Tozer P, Daulatzai N, Burling D, Hart A, Athanasiou T, Phillips RK
(2012) A diagnostic accuracy meta-analysis of endoanal ultrasound and MRI for perianal fistula
assessment. Dis Colon Rectum 55(5):576–585
Tan KK, Koh DC, Tsang CB (2013) Managing deep postanal space sepsis via an Intersphincteric
approach: our early experience. Ann Coloproctol 29(2):55–59
Tonkin DM, Murphy E, Brooke-Smith M, Hollington P, Rieger N, Hockley S, Richardson N,
Wattchow DA (2004) Perianal abscess: a pilot study comparing packing with nonpacking of the
abscess cavity. Dis Colon Rectum 47(9):1510–1514
Toyonaga T, Matsushima M, Tanaka Y, Shimojima Y, Matsumura N, Kannyama H, Nozawa M,
Hatakeyama T, Suzuki K, Yanagita K, Tanaka M (2007) Microbiological analysis and endoanal
ultrasonography for diagnosis of anal fistula in acute anorectal sepsis. Int J Color Dis 22(2):
209–213
Vaizey CJ, Carapeti E, Cahill JA, Kamm MA (1999) Prospective comparison of faecal incontinence
grading systems. Gut 44(1):77–80
Vasilevsky CA, Gordon PH (1984) The incidence of recurrent abscesses or fistula-in-ano following
anorectal suppuration. Dis Colon Rectum 27(2):126–130
Vogel JD, Johnson EK, Morris AM, Paquette IM, Saclarides TJ, Feingold DL, Steele SR (2016)
Clinical practice guideline for the management of anorectal abscess, fistula-in-Ano, and
rectovaginal fistula. Dis Colon Rectum 59(12):1117–1133
Wei PL, Keller JJ, Kuo LJ, Lin HC (2013) Increased risk of diabetes following perianal abscess: a
population-based follow-up study. Int J Color Dis 28(2):235–240
Yano T, Asano M, Matsuda Y, Kawakami K, Nakai K, Nonaka M (2010) Prognostic factors for
recurrence following the initial drainage of an anorectal abscess. Int J Color Dis 25(12):
1495–1498
Zanotti C, Martinez-Puente C, Pascual I, Pascual M, Herreros D, Garcia-Olmo D (2007) An
assessment of the incidence of fistula-in-ano in four countries of the European Union. Int J
Color Dis 22(12):1459–1462
The Seton in Anal Fistula Management
16
Jacopo Martellucci and Maria Laura Vuolo
Contents
1 Introduction .................... ............................... ............................. 252
2 2500 Years of Setons ....................................................................... 252
3 To Put or Not to Put ....................................................................... 253
4 To Cut or Not to Cut....................... ................................................ 254
5 What Kind of Seton to Use? ............ ................................................... 255
6 Draining Seton as the Only Treatment (A Pathophysiological Paradox?) ................ 256
7 Seton 2.0: New Perspectives ............................................................... 258
8 Uncomfortable Questions (How to Do It) ... . ........................... .................. 259
9 What Patients Should Know ................................... ............................ 260
10 Conclusions: Seton in Guidelines ......................................................... 261
References ............................ ............................................... ............ 263
Abstract
Fistula-in-ano is a challenging problem where treatment attempts have been
traced back to the days of Hippocrates and even earlier. Surgical treatment of
fistula-in-ano is dictated by the amount of sphincter involved and internal and
external anal sphincters preservation is in the interest of continence maintenance.
There are a variety of reasons to use setons in the management of anal fistulas.
They consent to drain the track preparatory to an attempted repair (bridge to
sphincter preserving techniques), as a way of staging fistulotomy, or to set the
stage for spontaneous healing. Although many advocate that loose seton placement should be the gold standard in the management of complex fistula, existing
literature results often consist of small/medium volume case series with limited
follow-up and conflicting results when compared to other techniques, still leaving
to the surgeon the choice of the best treatment based on personal experience and
patients’ characteristics.
J. Martellucci (*) · M. L. Vuolo
Emergency Surgery/Pelvic Floor Center, Careggi University Hospital, Florence, 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_18
251
252 J. Martellucci and M. L. Vuolo
However, despite the heterogeneity of the studies on this topic, the variability
of the results and their methodology usually retrospective and with short followup remains the impression that although the seton is an ancient treatment, its role
in fistula management is still predominant and can be further explored.
Keywords
Anal fistula · Seton · Cutting seton · Loose seton · Surgical treatment · Drainage
1 Introduction
Over the years a wide range of treatments have been described in an attempt to treat
fistula-in-ano, aiming to achieve the closure of the fistula but also preserving
sphincteric function and minimizing healing times. However, while fistulotomy is
still regarded by many as the gold standard for lower and simple fistula, questions
remain about how to treat the more complex ones, and none of the available
treatments is currently accepted as the gold standard. Moreover, excluding fistulas
in which fistulotomy can be primarily safely performed, the insertion of a seton is
considered by many a prerequisite for a successful treatment. There are a variety of
reasons for which a seton can help in the management of anal fistula: it can drain the
tract before an attempted repair or a fistulotomy, dry secondary tract and simplify the
primary tract, lower the fistula, or perform a time-controlled fistulotomy with a
regulated traction. Nowadays it is believed that the most correct treatment of anal
fistula is tailored to each individual case using various techniques according to the
clinical features. Even accepting this perspective, the seton maintains a fundamental
function for the management of these patients.
2 2500 Years of Setons
Fistula-in-ano is a challenging problem where treatment attempts have been traced
back to the days of Hippocrates and even earlier.
In the ancient Indian medicine, Sushruta (estimated between 1200 and 600 BC),
one of the most significant Indian medical writers, wrote a medical book (samhita)
where in addition to amputation, lithotomy, and rhinoplasty, hernia surgery speaks
about the perianal fistulas and their treatment by burning with a hot iron (cauterization) and pulling the fibers soaked with plant alkaloids that destroy callus tissue of
fistula and encourage fresh growth of granulation tissue (Ksharasutra therapy)
(Maksimovic and Maksimovic 2013).
However, the documented history of fistula management with seton started with
Hippocrates (460–377 BC). The word seton (from the Latin setu, meaning bristle)
refers to any foreign material inserted through the fistulous tract. In ancient Greek
medicine, fistula surgeries were carried out by Hippocratic school doctors by pulling
of the linen threads or horsehair through the fistula using a tin probe, with its gradual