jcoloproctol(rioj).2016;36(3):149–152
w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Original
Article
Perianal
abscess:
a
descriptive
analysis
of
cases
treated
at
the
Hospital
Santa
Marcelina,
São
Paulo
夽
Isaac
José
Felippe
Corrêa
Neto
a,b,∗,
Janaína
Wercka
a,
Angelo
Rossi
Silva
Cecchinni
a,
Eduardo
Augusto
Lopes
a,b,
Hugo
Henriques
Watté
a,b,
Rogério
Freitas
Lino
Souza
a,
Alexander
Sá
Rolim
a,b,
Laercio
Robles
a,caHospitalSantaMarcelina,DepartamentodeCirurgiaGeral,Servic¸odeColoproctologia,SãoPaulo,SP,Brazil bSociedadeBrasileiradeColoproctologia,Brazil
cColégioBrasileirodeCirurgia,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received18September2015 Accepted22March2016 Availableonline13April2016
Keywords:
Perianalabscess Medicalhistory
Signsofsyndromeofsystemic inflammatoryresponse Surgery
Seasonality
a
b
s
t
r
a
c
t
Introduction:Perianalsuppurationshaveanincidenceof1–2:10,000inhabitantsperyearand representabout5%ofproctologyconsultations,morefrequentlyinmales,beingrarein childhood.Althoughperianaloranorectalabscessisanentityofrelativelysimplediagnosis andtreatment, ina considerablepercentageofpatientsdifficultieswillbefound, espe-ciallyconsideringthattheinitialtreatmentofthesepatientsisperformedbynon-specialist physicians.
Objective:Thisisaretrospectivesurveyofcasesofperianalandanorectalabscessoperated inSantaMarcelinaHospitalbetweenOctober2011andDecember2014.
Patientsandmethods:Aretrospectivestudyofpatientsoperatedonanemergencybasisfor perianaland/oranorectalabscessinSantaMarcelinaHospitalbetweenOctober2011and December2014,beingexcludedpatientswithinflammatoryboweldisease.Dataofgender, age,clinicalpresentation,theseasonoftheyearinwhichtheabscessoccurred,timeof pro-gressionofsymptoms,comorbidities,signsofSystemicInflammatoryResponseSyndrome (SIRS)onadmission,surgeriescarriedout,reoperationsandclinicaloutcomewereanalyzed.
Results:Electronicmedicalrecordsof52patients(73.1%male)whounderwentsurgical treat-mentofanorectalandperianalabscesswereanalyzed.Themeanoverallagewas43.03years, andallpatientsreportedpainasthemainsymptom,withameantimeofsymptomsof6.5 days.Asfortheseasonoftheyearofonsetanddiagnosisofperianalabscess,61.5%of patientshadthispathologyinthesummerandspringmonths.
夽
StudyconductedbyProgramofMedicalResidency inColoproctology,DepartmentofGeneralSurgery,HospitalSantaMarcelina, SãoPaulo,SP,Brazil.
∗ Correspondingauthor.
E-mail:isaacneto@hotmail.com(I.J.F.C.Neto).
http://dx.doi.org/10.1016/j.jcol.2016.03.004
150
jcoloproctol(rioj).2016;36(3):149–152Conclusion: Inourstudy,itcanbeobservedahigherincidenceofperianalabscessinmales andinthewarmermonths;furthermore,justoverhalfofthepatientsdevelopedperianal fistulaintheirprogression.
©2016SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.Thisis anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Abscesso
perianal:
análise
descritiva
de
casos
atendidos
no
Hospital
Santa
Marcelina,
São
Paulo
Palavras-chave:
Abscessoperianal Históriaclínica
Sinaisdesíndromedaresposta inflamatóriasistêmica Cirurgia
Sazonalidade
r
e
s
u
m
o
Introduc¸ão: Assupurac¸õesperianaisapresentamumaincidênciade1-2:10000habitantes poranoerepresentamcercade5%dasconsultasproctológicas,commaiorfrequênciano sexomasculino,sendorarasnainfância.Emboraoabscessoperianalouanorretalsejade diagnósticoetratamentorelativamentesimples,umapercentagemconsiderávelrepresenta maiordificuldadeparatal,notadamentepelofatodoatendimentoinicialdessespacientes serrealizadopormédicosnãoespecialistas.
Objetivo: Levantamentoretrospectivodoscasosdeabscessoperianaleanorretaloperados noHospitalSantaMarcelinaentreoutubrode2011edezembrode2014.
Casuísticaemétodo: Estudoretrospectivodepacientesoperados emcaráterde urgência porabscessoperianale/ouanorretalnoHospitalSantaMarcelinaentreoutubrode2011 edezembrode2014,excluídosportadoresdedoenc¸ainflamatóriaintestinal. Analisaram-sedadosdesexo,idade,quadroclínico,épocadoanodaocorrênciadoabscesso,tempo de evoluc¸ãodos sintomas,comorbidades,sinaisdeSíndrome daResposta Inflamatória Sistêmica(SIRS)naadmissão,cirurgiasrealizadas,reoperac¸õesedesfechoclínico.
Resultados: Foramanalisadosprontuárioseletrônicosde52pacientessubmetidosà trata-mento cirúrgicode abscessoanorretale perianal,dosquais 73,1%pertenciam aosexo masculino.Amédiadeidadegeralfoide43,03anosetodosospacientesrelataramdorcomo sintomaprincipalcommédiadetempodesintomatologiade6,5dias.Quantoàépocado anodoaparecimentoediagnósticodoabscessoperianal,61,5%dospacientesapresentaram apatologianosmesesdeverãoeprimavera.
Conclusão: Emnossotrabalho,pode-seobservarmaiorincidênciadeabscessoperianalno sexomasculino enosmesesmaisquentesequepouco maisda metadedospacientes desenvolveramfístulaperianalnaevoluc¸ão.
©2016SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Introduction
Perianalabscessisdefinedasacollectionofpuslocatedin perinealtissues1 and isthe mostcommon proctologic
dis-ease requiring an emergency surgical treatment.2 On the
otherhand,anorectalabscesses resultofacryptoglandular infection,3usuallyofidiopathicetiology4andlocatedinthe
inter-sphinctericspace.5
But although most of the time perianal or anorectal abscesses are an entity of relatively simple diagnosis and treatment,inaconsiderablepercentageofpatients,difficulties willbefound,especiallyconsideringthattheinitialtreatment ofthesepatientsisperformedbynon-specialistphysicians.6
Anorectal abscesses are classified into five types, with incidencesdefined:perianal (60%), ischiorectal(30%), inter-sphincteric(5%),supraelevator(4%)andsubmucosal(1%).7
Perianal suppurations have an incidence of 1–2:10,000 inhabitantsperyearandrepresentabout5%ofallproctology
consultations, beingmorefrequentinmales andoccurring uncommonly in children.5,8 In the United States, the
esti-matedincidenceisbetween68,000and96,000casesperyear. However,theactualincidenceofperianalabscessesis under-estimated,consideringthatthisisaconditionthatnowadays canbeseenwithspontaneousdrainage;inaddition,thereis thepossibilityoftreatmentintheemergencyroomitself,or eveninthephysician’soffice.9
Inthisstudy,ourgoalwastoconductaretrospectivestudy ofcasesofperianalandanorectalabscessoperatedinSanta MarcelinaHospitalbetweenOctober2011andDecember2014.
Materials
and
methods
jcoloproctol(rioj).2016;36(3):149–152
151
Table1–Symptomatologyofpatientswithperianaland anorectalabscess.
Ache 52(100%)
Bulging 23(44.2%) Secretion 9(17.3%) Signsofinflammation 9(17.3%)
HospitalbetweenOctober2011andDecember2014;patients withinflammatoryboweldiseasewereexcluded.
Gender,age,clinicalpresentation,theseasonoftheyearin whichtheabscessoccurred,timeofprogressionofsymptoms, comorbidities, signs of Systemic Inflammatory Response Syndrome(SIRS)onadmission,surgeriescarriedout, reoper-ations,andclinicaloutcomeswereanalyzed.
Results
Electronicmedicalrecords of52 patients(73.1% male)who underwent surgical treatment of anorectal and perianal abscesswereanalyzed.Themeanoverallagewas43.03years (20–77years),withthesamemeanageinmales,and42.2years forfemales.
Withregardtocomplaints,allpatientsreportedpainasa symptom,23patients(44.2%)reportedperianalbulgingand9 (17.3%)informeddischargeandsignsofinflammation(17.3%)
(Table1).Themeantimeofprogressionofsymptomswas6.5
days,rangingfrom1to30days.Halfofthepatientshadno comorbidities,21.2%weresmokersand15.4%werecarriersof diabetesmellitus.AsforsignsofSIRSonadmission,thiswas foundinonly3patients(5.8%).
Asfortheseasonoftheyearintheonsetanddiagnosisof perianalabscess,61.5%ofpatientshadthispathologyinthe summerandspringmonths.
In47patients(90.4%)onlyabscessdrainagewascarried out;inonecasetherewastheneedforacolostomy,asthis patientwasdiagnosedwithnecrotizingfasciitis intraopera-tively.Intheremaining5patients(9.6%)drainageandpassage ofaSetonwereconducted.Inonlyonepatient,excludingthe caseofnecrotizingfasciitis,areoperationwasrequiredwithin thefirst10daysaftertheinitialsurgery.
Themeanhospitalizationtimewas1.63days(1–21days) and aftertheexclusion ofthe patientwithFournier’s gan-grene,thismeantimedecreasedto1.25days,rangingfrom1 to3days.Twenty-ninepatients(55.8%)werelosttooutpatient follow-up;thus,itwasnotpossibletoassesstheiroutcome. Thirteenof23remainingpatients(56.5%)developeda peri-analfistulaintheirprogressionand10(43.5%)patientswere dischargedwithoutanewsurgicalapproach.
Discussion
As the terminal portion of the rectum goes through the pelvicfloormuscles,becomingtheanalcanal,creasesknown ascolumnsofMorgagni,are formed;inthesecreases,anal cryptsarelocatedattheirlowerend.8Microtraumaandfecal
stasis induced in these glands explainthe formation of a pyogenic cryptitis with subsequent formation ofanorectal abscesses.3,10
Abcarian et al.,9 taking into account that 26–37% of
abscessesevolvetoafistula,11,12andanalyzingdataaboutthis
disease,reportanannualincidenceofanorectalabscessesof 68,000–96,000casesperyearintheUnitedStatesofAmerica. Theseauthorsalsoreportthatmostpatientswithanorectal suppurationareagedbetween20and60years,withamean of40years.Furthermore,studieshavereportedanincidence twiceashighinmen,reachingupto83.9%ofcases.4,11,13
Sim-ilarly,wefoundinourstudyameanageof43.03years,more frequentlyinmale(73.1%ofcases).
Clinically,thisdiseaseismanifestedbyaconstantand pro-gressiveacutepainthatmayworsenwithdefecation,5besides
showinganassociationwithsignsofSystemicInflammatory ResponseSyndrome(SIRS).Incasesofperianalabscess,one canfindalocalhyperemiaandpainwithfloatingandcellulitis initsperiphery.8,14
Sometimes,and insituations ofdeeperabscesses,these signalsaremoredifficulttobefound,andthephysicianshould valuedigitalrectalexaminationandcomplementary investi-gation,eitherbyCT,pelvicMRI,orendoanalultrasound.15
Czeigeretal.1carriedoutonesurveyandanalysisof1415
patientsenrolledinthestudyover11yearsandfoundthat 73.6%weremaleandthatthemeanhospitalizationtimewas 2.1±0.8days.Onehundredandeighty-eightpatients(16.4%) required more than one abscess incision/drainage surgery duringhospitalization;amongthesepatients,21.8%hadmore thanonerecurrence.Inthisstudy,itwasfoundthatonlytwo patients(3.8%)requiredreoperation,andoneofthemsuffered necrotizingfasciitis.
Inthisrespect,Akkapuluetal.4evaluated93patientswith
anorectal abscessand soughtto identifyfactors related to clinical recurrence.These authorsfoundthatthere wasno statisticallysignificantcorrelationwithrespecttogender,age, typeofabscess,useofadrain,andfistulaidentificationinthe firstsurgery.
Althoughsomestudieshavenotobservedanoccurrenceof predispositionwithseasonalityorcertainmonths,9Vasilevsky
and Gordon12 reported a higher prevalence in June
(sum-merintheircountries)andalowerincidenceinAugustand September.Weobservedthat therewasahigherincidence ofdiagnosesofperianal abscessinthesummer andspring months(61.5%).
Consideringthat inmostcasesofanorectal abscessthe patientsareseenandoperatedonanemergencybasis,Jimeno et al.16 conductedoneprospective study inorder toverify
theimportanceoftheclinicalsymptomsintheaccuracyof anorectaldisorders.Forthispurpose,theseauthorsdivided thegroupbetweensurgeonsandphysicianswithclinical spe-cialties,involvingatotalof44participants.Inourstudy,ithas beenfoundthatbothgroupswereabletodiagnosepatients withanorectalabscesssolelyviewingimagesin100%versus 80.4%, respectively, that is, betweensurgeons and medical doctors(p=0.157).However,greateraccuracyforall partici-pantswasfoundwhentheclinicalhistorywasassociatedwith theimageoftheabscess(p=0.025).
152
jcoloproctol(rioj).2016;36(3):149–152proctologicexaminationwithdigitalrectalexaminationand anoscopy.Theliteraturerecommendsthatincasesof inter-sphinctericorlowtransphincteric fistulas,onecanmakea fistulotomy;andincasesofdoubtorofcomplexfistulas,one mustintroduceaSeton.8,17,18
Ontheotherhand,consideringthattheperianalabscess drainagesurgeryisusuallyperformedbygeneralsurgeons(in somecasesnotveryfamiliar withanorectalanatomy),and alsoconsideringthelocalsepticprocesswithlossofnormal architecture,webelievethat themaking ofalargeabscess drainage atthe nearest possible point from the anal mar-ginand paralleltothe fibersofthe externalanal sphincter muscle,5alongwithdebridementofdevitalizedtissueandthe
introductionofaSetonincasesofidentificationofaninternal fistulousorificewouldbethemostprudentstrategy.Czeiger etal.1alsosharethisviewandrecommendthatthe
fistulo-tomy shouldbeperformed onlywhenthe surgeryisbeing performedbyanexperiencedproctologist.
With respectto the implementation and application or non-applicationofalatexdraintotheabscesscavity, Billing-hametal.19recommendthattheattendingsurgeonrelinquish
(orcan giveup)this procedure, providedthat anadequate drainagehasbeenobtained.Ontheotherhand,oneshould recommendapost-operativeprocedurewiththeuseof antibi-otics in patients with diabetes, morbid obesity, immune deficiency,incardiacprosthesisusers,orincasesof exten-sivecellulitis.3,9Furthermore,itisimportantthatinsituations
of persistent fever, cellulitis or leukocytosis after the ini-tialdrainage,thesurgeonproceedstoananorectalsurgical exploration.9Stillwiththatinmind,Sözeneretal.13
demon-stratedthatpostoperativetreatmentwithantibiotictherapy doesnotdecreasetheriskofafutureformationofananorectal fistula.
Conclusion
Our study corroborates literature data on the prevalence ofgender and prevalenceperiod, drawing attention tothe seriousnessthatsomecasesmayrepresentintheevent of progressiontonecrotizingfasciitisandtheneedtofine-tune theinitialtreatment,respectingthedegreeofknowledgeand expertiseoftheattendingphysician,inordertoavoid seri-ousandpermanentsequelsofsuchacommonpathologyin emergencyrooms.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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