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Anorectal abscess on call

Anorectal abscess on call. Jim Hill Manchester Royal Infirmary. Anorectal abscess distribution. Perianal 43-57% Ischiorectal 23-34% Intrasphincteric 7-21% Supralevator 1- 8%. Anorectal abscess – de Pezzer drainage – Isbister ANZJS 1987. Local anaesthetic 10% intolerable pain

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Anorectal abscess on call

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  1. Anorectal abscess on call Jim Hill Manchester Royal Infirmary

  2. Anorectal abscess distribution • Perianal 43-57% • Ischiorectal 23-34% • Intrasphincteric 7-21% • Supralevator 1- 8%

  3. Anorectal abscess – de Pezzer drainage – Isbister ANZJS 1987 • Local anaesthetic • 10% intolerable pain • 29% developed fistula in follow up period

  4. Anorectal abscess and fistula - USA. A study of 1023 pts. Abcarian et al Dis Colon Rectum 1984 • Regional anaesthesia, early aggressive treatment of low fistula • 35% internal opening (3% sup/sphincteric) • 3.7% recurrence abscess only group • 1.8% recurrence primary fistulotomy group

  5. Anorectal and fistula – UK. Winslett at al Dis Col Rectum 1988 • 233 pts • 5% internal opening • 32% reoperation in incision and drainage category • 12% occult disease

  6. Anorectal abscess and fistula - incidence • Abcarian 35% • Gordon 37% • Mazier 69% • Winslett 5%

  7. Primary fistulotomy-perianal abscess – Seow-Choen et al Dis Colon Rectum 1997 • Randomised trial 52 consecutive patients • Persistent fistulas • 25% I&D group • 0% Fistulotomy group • No difference in continence or ARPS • Operating time, hospital stay, wound healing no different

  8. Early re-operation for anorectal abscess • Onaca et al Mayo Dis Colon Rectum 2001 500 consecutive patients, 627 procedures 7.6% (48 pts) re-operation rate – 10 days 23 incomplete drainage 19 missed loculations/abscess Horseshoe abscess 50% failure rate Surgical error leading cause early failure

  9. Horseshoe abscess

  10. Horseshoe abscess • Drain bilaterally • Ensure adequate skin excision • Insert seton

  11. Primary suture of anorectal abscess – Mortenson et al Dis Col Rectum 1995 • Randomised trial 107 patients • Clindamycin vs clindamycin and gentacoll • Any fistula detected layed open • Recurrence 17% vs 22%

  12. Good News/low risk Small abscess First abscess Young Healthy Bad News/high risk Large, bilateral Previous abscess Old Cardiorespiratory disease Crohn’s disease Fat Obese Immunosuppression Instructions to the BST

  13. Debriding agents • Systemic review Health Technology Assessment 2001 • No good trials • All used autolytic methods • Modern dressings (foam, alginate, hydrocolloid) vs gauze • Suggestion better than gauze for healing, pain, dressing performance and resource use

  14. Crohn’s disease • Abscess always associated with a fistula • Loose draining setons • Avoid fistulotomy • Recurrence rates >50% at two years • Recurrence rates less in patients with stomas

  15. Supralevator abscess • Suspect intra-abdominal pathology • Internal opening-seton drainage • Supralevator component-mushroom catheters

  16. Haematological malignancies 1 • Incidence 7-10% • Neutrophil count significant prognostic factor • Mortality 20-50% • Organisms same as non-immunocompromised patients • Pus can form even in patients with severe neutropaenia

  17. Haematological malignancies -2 • Evaluate rectal pain and fever carefully • Start broad spectrum antibiotics • Beware rapid progression to Fournier’s • Incision and drainage when fluctuation present • Role of surgery uncertain in non-resolving cellulitis

  18. HIV and perianal abscess • Anorectal pathology not impacted by highly active antiviral therapy • Disturbed wound healing more common (4-34%) and related to low CD4+ counts (< 200 x106) • Serious septic complications higher (15%) • Idiopathic anal canal ulcer commonly associated with inter-sphincteric abscess

  19. Acute pilonidal abscess – incision and drainage • Br J Surg 1988 Jensen and Harling • 73 pts all had symptoms resolved • 58% healed primarily in 10 weeks • 12% later recurrence • 45% healed overall • Increased recurrence rates in those with more pits and lateral sinus

  20. Pilonidal abscess – primary closure with antibiotic cover • Eur J Surg 1993 • 56 patients one or four days ampicillin/flagyl • 30% recurrence • No difference with antibiotic regimes

  21. Perianal hidradenitis

  22. Summary • Train the BST • Send pus and skin • High risk cases • Assess preoperatively • Be present in theatre • Low fistulas can be dealt with safely • Use modern dressings

  23. MCQ • Which of the following statements with haematological malignancies and anal infections is true A. The development of a perianal abscess is independent from the granulocyte count B. The most common causative agent is candida C. The overall prognosis for the haematological cancer is independent from the prescence of septic complications D. The pus found at the time of the incision and drainage is identical to pus drained from common perianal abscesses E. Fever is an important element in the clinical presentation of such cases

  24. Horseshoe abscess

  25. Horseshoe abscess • Bilateral drainage • Insertion of seton through internal opening

  26. Radiology • US scanning • 63% accuracy relation abscess and Park’ classification • 28% accuracy locating internal opening

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