J. Coloproctol. (Rio J.) vol.36 número4

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jcoloproctol(rioj).2016;36(4):216–219

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Original

Article

Incidence

of

fistula

after

management

of

perianal

abscess

Riyadh

Mohamad

Hasan

UniversityofBaghdad,Al-KindyCollegeofMedicine,DepartmentofSurgery,Baghdad,Iraq

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Articlehistory:

Received2May2016 Accepted15May2016 Availableonline5July2016

Keywords:

Fistula Perianal Abscess

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Background:Perianalfistulaisamongthemostcommonanorectaldiseasesencountered inadults,menaremorepronetobeaffectedthanwomen.Thereisacloserelationship ofabscessandfistulainetiology,anatomy,pathophysiology,therapy,complicationsand morbidity,itisappropriatetoconsiderthemasoneentity.

Aimofstudy:Todeterminetheincidenceoffistulaformationandrecurrentabscessina sampleofIraqipatientsinBaghdadanddecidewhetherprimaryfistulotomyshouldbe performedatthetimeofincisionanddrainageofperianalabscesses.

Patientsandmethods:Aretrospectivestudyof68patientswithperianalabscessoperations conductedinBaghdad.Theyunderwentincisionanddrainageundereitherlocalorgeneral anesthesiaatAl-KindyTeachingHospitalsandprivatehospitalsovera15-yearperiodfrom January2000toDecember2015.Theiragesrangedfrom20to68years(40.21±1.34)males (63/68)(92.64%)weremorethanfemales(5/68)(7.35%).Patientsweretreatedwithincision overtheabscessunderanesthesiaanddrainageoftheabscesswasdone.Thepatientswere followedupforanaverage18months(range12–24months)afterabscessdrainageoruntil afistulaappearedandabscessrecurrence.

Results:Thestudygroupcomprisedof68(92.64%)patientswithperianalabscesswitha medianage39years(range20–68years).Themeanfollow-upperiodwasidentifiedtobe18 months(range12–24months).Males(63/68)(92.64%)weremorethanfemales(5/68)(7.35%). Theincidenceoffistulaformationafterfollowup,thepatientswithperianalabscessafter incisionanddrainagewas31/68(45.58%)andmales(30/31)(44.11%)weremorethanfemales (1/31)(1.47%).Themostcommonsitewasposteriorthenleftlateralposition.The percent-ageofpatientswithrecurrentabscessn=6(8.82%)werelowerthanfistulaformationn=31 (45.58%).Thepercentageofmalesn=4/6(5.88%)weremorethanfemales2/6(2.94%).

Conclusions:TheincidenceofanalfistulainasampleofIraqipatientswithperianalabscess was45.58%andpercentageofrecurrenceofperianalabscesswas8.82%.Toavoiddivisionof

E-mail:[email protected] http://dx.doi.org/10.1016/j.jcol.2016.05.002

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jcoloproctol(rioj).2 0 1 6;36(4):216–219

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analsphinctermuscle,secondaryfistulotomyisadvisedtobedonelaterwhenanalfistula willbeformed.

Incidência

de

fistulas

em

seguida

ao

tratamento

de

abscesso

perianal

Palavras-chave:

Fístula Perianal Abscesso

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Experiência: Afistulaperianalestáentreasmaiscomunsdoençasanorretaisobservadasem adultos;oshomensdemonstrammaiortendênciaparaseremafetados,emcomparação comasmulheres.Existeíntimarelaçãoentreabscessosefistulasemtermoseetiologia, anatomia,fisiopatologia,tratamento,complicaçõesemorbidade;assim,écabível considerá-loscomoumamesmaentidade.

Objetivodoestudo:Determinaraincidênciadeformaçãodefístulasedeabscessorecorrente emumaamostradepacientesiraquianosemBagdá,edecidirseafistulotomiaprimáriadeve serrealizadaporocasiãodaincisãoedrenagemdeabscessosperianais.Pacientese méto-dos:Estudoretrospectivode68pacientescomoperaçõesparaabscessoperianalrealizadas emBagdá.FoirealizadaincisãoedrenagemsobanestesialocalougeralnoHospital-Escola Al-Kindyeemhospitaisprivadosaolongodeumperíodode15anos,dejaneirode2000até dezembrode2015.Asidadesvariavamde20a68(40,21±1,34)anos.Haviamaiornúmerode homens(63/68)(92,64%)doquedemulheres(5/68)(7,35%).Ospacientestiveramoabscesso tratadosobanestesia,efoirealizadaadrenagemdoabscesso.Ospacientesforam moni-torados,emmédia,durante18meses(variação,12-24meses)apósadrenagemdoabscesso, ouatéosurgimentodeumafístulaerecorrênciadoabscesso.

Resultados: Ogrupodeestudocompreendeu68(92,64%)pacientescomabscessoperianal, comidademedianade39anos(variação,20-68anos).Operíodomédiodeseguimentofoide 18meses(variação,12-24meses).Haviamaiornúmerodehomens(63/68)(92,64%)versus mulheres(5/68)(7,35%).Noseguimento,aincidênciadeformaçãodefístulanospacientes comabscessoperianalapósaincisãoedrenagemfoide31/68(45,58%),eoshomensforam maisafetados(30/31)(44,11%)versusmulheres(1/31)(1,47%).Olocalmaiscomumfoia posiçãoposteriore,emseguida,alateralesquerda.Opercentualdepacientescomabscesso recorrente(6,8,82%)foimaisbaixodoqueopercentualparapacientescomformaçãode fístula(31,45,58%).Opercentualdehomens(4/6,5,88%)foimaiorversusmulheres(2/6, 2,94%).

Conclusões: A incidênciadefístulaanalemumaamostra depacientesiraquianoscom abscessoperianalfoide45,58%eopercentualderecorrênciadeabscessoperianalfoide 8,82%.Paraevitaradivisãodomúsculoesfinctéricoanal,éaconselhávelfazeruma fistulo-tomiasecundáriamaistarde,quandoafístulaanaljáestiverformada.

Introduction

Fistula is among the most common anorectal diseases encounteredin adults,Men are moreprone to beaffected than women.1 _There_is _a_close_relationship_of_abscess_and

fistulainetiology,anatomy,pathophysiology, therapy, com-plicationsandmorbidity,itisappropriatetoconsiderthemas oneentity.2_A_previous_history_of_perianal_abscess_can_usually

bementionedanddrainedeitherspontaneouslyorsurgically underlocalorgeneralanesthesia,thusafistula-in-ano rep-resentsthechronicphaseofongoingperianalabscess.3_It_is_a

commondiseasewithanincidenceofabout2casesper10,000 populationperyearandlikelytooccurbetweentheagesof 30 and50 years.4 _Fistula _in_ano_are _either _associated_with

perianalabscessfromoutsetorasalatersignin26–37%ofthe time.5–7 _After_drainage_the_abscess,_probe_the_{corresponding}

analcryptgently,lookingforafistulainano.Primary fistulo-tomymaybeattemptedwhenitisidentifiedandsuperficial.8

About1000primaryfistulotomiesweredoneduringdrainage ofanabscesswithnoadverseresults.9_One_can_suspect

devel-opmentoffistulalateronwhenthereisaprolongeddrainage fromanincisionsitebeyond2–3monthsandabscessheals andrecursatthesamefirstlocation.10_Abscess_recurrence_and

lateronfistulaformationisduetoinsufficientdrainageand lateonsetdrainage.11–13_The_incidence_of_fistula_following_an

abscessincisionanddrainagewas26%andincidenceof recur-rentabscesswas37%.14,15_The_anal_canal_should_be_searched

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Table1–Incidenceoffistulainanoandrecurrentabscessafterfollow-uppatientswithperianalabscess.

Patientswithperianalabscess,n=68 Cure

n=31(45.58%)

Fistulaformation

n=31(45.58%)

Recurrentabscess

n=6(8.82%) Males

n(%)

Females

n(%)

Males

n(%)

Females

n(%)

Males

n(%)

Female

n(%) 29(42.64) 2(2.94) 30(44.11) 1(1.47) 4(5.88) 2(2.94)

Initialsites Site Males

n(%)

Females

n(%)

Males

n(%)

Females

n(%)

Males

n(%)

Females

n(%) 1.Posterior 11(35.48) 5(16.12) 16(51.61) 3(9.67) 4(66.66) 2(33.33) 2.Rightlateral 5(16.12) 0(0) 0(0) 0(0) 0(0) 0(0) 3.Leftlateral 10(32.25) 0(0) 12(38.70) 0(0) 0(0) 0(0)

superficial, primary fistulotomy may be attempted using a loosesetonofbraided,nonabsorbablesuturethatinsertedinto thefistulatract,tiedlooselytoactasadrain.Thisistermeda “primary”or“synchronous”fistulotomywhichiscurativeand avoidtheneedforsubsequentfistulasurgery.8,10_On_the_other

hand,abouttwothirdsofperianalabscessesneverprogress tofistulasandthat aprimaryfistulotomy withits possible complicationsisusuallyunnecessaryand thepatientswho areidealcandidatesforprimaryfistulotomyarealsothe eas-iesttotreat withdelayedfistulotomy withsubsequentlow morbidity.3_Thus,_the_prudent_rule_would_be_to_defer

fistulo-tomyuntilthefistulabecomesobvious.

Theaimofthisstudywastoassesstheincidenceofanal fistulaand recurrentabscessafterincisionand drainageof perianalabscessinasampleofIraqipatientsinBaghdadand decidewhetherprimaryfistulotomyshouldbeperformedat thetimeofincisionanddrainageofanorectalabscesses.

Patients

and

methods

Aretrospectivestudyof68patientsoperateduponfor peri-analabscessconductedinBaghdad.Theyunderwentincision anddrainageundereitherlocalorgeneralanesthesiaat Al-KindyTeachingHospitalsandprivateHospitalsovera15-year periodfromJanuary2000toDecember2015.Theiragesranged from20to68years(40.21±1.34)males(63/68)(92.64%)were morethanfemales(5/68)(7.35%).Theinclusioncriteriawere adultsaged18yearsandabovewhopresentedwithperianal abscess,whiletheexclusioncriteriawerepatientsunder eigh-teenyears,abscesswithknownfistula,complicatedabscesses (multipleorbilateralabscess),Crohn’sdisease, immunosup-pression,malignancy,necrotizingfasciitisanddisseminated tuberculosis.TheScientificandEthicalCommitteeofAl-Kindy MedicalCollegeandHospitalshadapprovedthestudy. Writ-teninformedconsentswereobtainedfromthepatientswith perianalabscesses.

Patientsweretreatedwithincisionovertheabscessunder anesthesia(localorgeneral)thatallowsthorough examina-tionanddrainageoftheabscessandopeningallloculiwas done.Thepatientswerefollowedupforanaverage18months (range,12–24months)afterabscessdrainageoruntilafistula appearedandabscessrecurrence.

StatisticalanalysiswasdoneusingMINITABstatistical soft-ware13.20.

Results

Thestudygroupcomprisedof68(92.64%)patientswith peri-analabscesswithamedianageof39years(range20–68years). Themeanfollow-up periodwas identifiedtobe18months (range12–24months).Males(63/68)(92.64%)weremorethan females (5/68) (7.35%). All of them had a perianal abscess managed byincision and drainageunder anesthesia.Their durationofhospitalstaywas1–2days.

Theincidenceoffistulaformationafterfollowingupthe patientsoperatedforperianalabscesswas31/68(45.58%)and males(30/31)(44.11%)weremorethanfemales(1/31)(1.47%). Themostcommonsitewasposteriorthenleftlateralposition asshowninTable1.Thepercentageofpatientswithrecurrent abscessn=6(8.82%)werelowerthan fistulaformationn=31 (45.58%).Thepercentageofmalesn=4/6(5.88%)weremore thanfemales2/6(2.94%).Themostcommonsitewasalso pos-teriortoanus.Thepercentageofcuredpatients,31/68(45.58%) wassimilartopercentageofpatientswhodevelopedfistula, 31/68(45.58%).Maleswererepresentingthehigherpercentage 42.64%thanfemales2.94%.posteriorabscessrepresentsthe commonsite35.48%followedbyleftlateral32.25%andlastly therightlateral16.12%.

Discussion

Abscess and fistula in ano are common cryptoglandular disease16 _which _is_most _common _in _people _aged _between

20 and 50 yearswithfour-fold male predominanceand an annualincidenceof1in10,000.17_That_is_in_agreement_with

our results, males were (63/68) (92.64%) that is more than females(5/68)(7.35%).Theirmedianagewas39years.Abscess after incision and drainage may manifests later on as fis-tulainanoandrecurrentabscessthatrequirerepeatsurgical drainage.Thus,treatingfistulaatthesametimemayreduce thelatesquealbutthiscouldaffectthefunctionoftheanal sphincter insomepatients who may nothave later devel-opedafistula-in-ano.18 _Our_study_showed_that_incidence_of

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wasposteriorthen leftlateralposition.Regarding recurrent abscess,thepercentageofpatientswas6/68(8.82%)thatwas lowerthanfistulaformation31/68(45.58%).Thepercentage ofmales4/6(5.88%)wasmorethanfemales2/6(2.94%)and themostcommonsitewasalsoposteriortoanus.Ourresults inaccordancewithotherresults,thatrecurrentabscessand fistulaformationoccurredin11%and37%respectively.This supportstheruleofsecondaryfistulotomytoavoiddivision of sphincter muscle in patients who would not need it.15

Otherreportshowedthatrecurrenceofabscesswas3.7%and fistulaformation was 34.7%, so early aggressivetreatment ofabscessreducesthepossibilityofrecurrenceandfurther surgery.8_Lohsiriwat _et_al.₍₂₀₁₀₎19 _found_that_the _incidence

offistula-in-anofollowingincisionanddrainageofperianal abscesswas31%.Riskfactorslikesex,smoking,alcohol,fever; leukocytosis,andlocationofabscesswerenotprognosticand predictiveoffistulaformation.Patientsagedlessthan40years andnon-diabetic appearedtohaveahigher riskforfistula formation (43%). Regarding administration of perioperative antibioticssignificantlyreducedtherateofsubsequentfistula formationto(17%). Meta-analysisstudy demonstrated that fistulasurgerywithabscessdrainagesignificantlyreduced fis-tula/abscessrecurrenceandneedforfurthersurgery.20_Sainio

(1984)1_reported_the_incidence_of_anal_fistula_during_ten_years

periodper100,000populationwas8.6fornonspecificand fis-tula,12.3formalesand5.6forfemales.Healsoreportedthat nonspecificfistulaeaccountedabout90.4%,thetuberculous fistulaeabout0.2%,thepostoperativeandtraumaticfistulae about3.3%andfistulaeoriginatinginanalfissureabout3.3% andtheoccurrenceofanalfistulaaftertreatmentofperianal abscesswas35%whileinourstudywas(45.58%).Otherstudy showedthat the incidence offistula-in-anofollowing peri-analabscesseswas26%diagnosedeitherduringfollow-upor within6months.21_The_differences_of_our_study_with_other

studiesmay bedue tosamplesize,criteria ofthepatients selectedinthestudy,durationoffollowup,useofantibiotics, sizeanddepthoftheabscessandsiteoftheabscess.Inour studythemostcommonlocationoftheabscesswasposterior, thisisduetomorefrequentanalglandslocatedposteriorly22,23

and morecommonlyfoundinmales than females.24 _Thus

diseaseismorecommoninmalesthanfemales.

Conclusions

TheincidenceofanalfistulainasampleofIraqipatientswith perianalabscesswas45.58%andpercentageofrecurrenceof perianalabscesswas8.82%.Toavoiddivisionofanal sphinc-termuscle,secondaryfistulotomyisadvisedtobedonelater whenanalfistulawillbeformed.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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