perianal abscess & anal fistulae by rajeev suryavanshi dept of general surgery

Perianal abscess & Anal Perianal abscess & Anal fistulaefistulae

ByBy

Rajeev SuryavanshiRajeev Suryavanshi

Dept of General Surgery.Dept of General Surgery.

Perianal abscessPerianal abscess

Definition -Definition -

• Infection of the soft tissue Infection of the soft tissue surrounding the anal canal, with surrounding the anal canal, with formation of discrete abscess cavity.formation of discrete abscess cavity.

• Often cavity is associated with Often cavity is associated with fistulous tract. fistulous tract.

Anorectal anatomyAnorectal anatomy

• Rectum develops from hind gut at 6 Rectum develops from hind gut at 6 weeksweeks

• Anal canal formed at 8 weeks – Anal canal formed at 8 weeks – ectoderm.ectoderm.

• Dentate line transition from endo to ecto.Dentate line transition from endo to ecto.• Rectum has inner – circular.Rectum has inner – circular. outer – longitudinal.outer – longitudinal.• Anal canal – 4cm, pelvic diaphragm to Anal canal – 4cm, pelvic diaphragm to

anal verge.anal verge.

Anatomy Anatomy

External Sphincter-External Sphincter- - U shaped , continuation of levator ani- U shaped , continuation of levator ani - deep segment is continuous with - deep segment is continuous with

puborectalis muscle and forms anorectal ring puborectalis muscle and forms anorectal ring felt on DRE.felt on DRE.

- striated muscle- striated muscle - voluntary control- voluntary control - 3 components - sub mucous, superficial and - 3 components - sub mucous, superficial and

deep.deep.

Anatomy-Anatomy-

• Internal sphincter-Internal sphincter-

- smooth muscle- smooth muscle

- autonomic control- autonomic control

- extension of - extension of circular muscles of circular muscles of rectum.rectum.

- contracted at rest.- contracted at rest.

Anatomy Anatomy

• 4-8 anal glands 4-8 anal glands drained by respective drained by respective crypts, at dentate line.crypts, at dentate line.

• Gland body lies in Gland body lies in intersphincteric plane.intersphincteric plane.

• Anal gland function is Anal gland function is lubrication.lubrication.

• Columns of MorgagniColumns of Morgagni

8-14 long mucosal 8-14 long mucosal fold. fold.

PathophysiologyPathophysiology

• Infection starts in crypto glandular Infection starts in crypto glandular epithelium lining the anal canal.epithelium lining the anal canal.

• Internal anal sphincter a barrier to Internal anal sphincter a barrier to infection passing from gut to deep infection passing from gut to deep perirectal tissue.perirectal tissue.

• Duct of Anal gland penetrate internal Duct of Anal gland penetrate internal sphincter into intersphincteric space.sphincter into intersphincteric space.

• Once infection sets in intersphincteric Once infection sets in intersphincteric space it can spread further.space it can spread further.

PathophysiologyPathophysiology

Infection & suppuration

abscess formation

Anal crypts obstruction

Glandular secretion stasis

FrequencyFrequency

• Common in 3Common in 3rdrd and 4 and 4thth decade of life decade of life

• Male > female (2:1)Male > female (2:1)

• 30% present with previous episodes.30% present with previous episodes.

• Increase incidence during summer and Increase incidence during summer and spring.spring.

• Common in infants , poorly understood Common in infants , poorly understood mechanism , fairly benign and majority mechanism , fairly benign and majority settle with simple drainage.settle with simple drainage.

EtiologyEtiology

• Abscess initially forms in the Abscess initially forms in the intersphincteric space and spreads intersphincteric space and spreads along adjacent potential spaces.along adjacent potential spaces.

• Common organisms-Common organisms-

* E.Coli* E.Coli

* Enterococcus species* Enterococcus species

* Bacteroides species.* Bacteroides species.

EtiologyEtiology

Less common causes -Less common causes -

• Crohn’s Disease.Crohn’s Disease.

• Cancer.Cancer.

• Tuberculosis.Tuberculosis.

• Trauma.Trauma.

• Leukemia.Leukemia.

• Lymphoma.Lymphoma.

Clinical featuresClinical features

Symptoms-Symptoms-• Pain Perianal Pain Perianal

movement ↑movement ↑ pressure ↑pressure ↑• PruritisPruritis• Generally unwell.Generally unwell.• Fever Fever • Chill and rigor.Chill and rigor.

Signs-Signs-• Swelling Swelling • CellulitisCellulitis• indurationinduration• FluctuationFluctuation• Subcutaneous mass, Subcutaneous mass,

near Perianal orifice.near Perianal orifice.• DRE- fluctuation at DRE- fluctuation at

times in ischorectal.times in ischorectal.

Classification of Anorectal Classification of Anorectal abscessesabscesses

• Perianal 60%Perianal 60%

• Ischiorectal 20%Ischiorectal 20%

• Intersphincteric 5%Intersphincteric 5%

• Supralevator 4%Supralevator 4%

• Submucosal 1%Submucosal 1%

Classification Classification

• PerianalPerianal – pus underneath skin of anal – pus underneath skin of anal canal, do not traverse external sphincter.canal, do not traverse external sphincter.

• IschiorectalIschiorectal – suppuration traversing – suppuration traversing external sphincter into Ischiorectal space.external sphincter into Ischiorectal space.

• IntersphinctericIntersphincteric – suppuration between – suppuration between external and internal sphincter.external and internal sphincter.

• Horse shoe abscessHorse shoe abscess - uncommon - uncommon circumferential infiltration of pus with in circumferential infiltration of pus with in intersphincteric space.intersphincteric space.

Investigation & ImagingInvestigation & Imaging

• No specific test requiredNo specific test required

• Patients with diabetes , Patients with diabetes , immunosuppresed will need lab immunosuppresed will need lab evaluation.evaluation.

• Imaging – role in only deep seated, Imaging – role in only deep seated, Supralevator or intersphincteric Supralevator or intersphincteric abscesses.abscesses.

CT Scan , MRI or Anal ultrasonography.CT Scan , MRI or Anal ultrasonography.

ManagementManagement

• Mainly surgical Mainly surgical

• Antibiotics in diabetics & Antibiotics in diabetics & immunocompromised individuals.immunocompromised individuals.

• Early drainage is indicated as Early drainage is indicated as delay can delay can cause-cause-

* prolong infection* prolong infection

* tissue destruction ↑* tissue destruction ↑

* chances of sphincter dysfunction ↑* chances of sphincter dysfunction ↑

* Promote fistula formation.* Promote fistula formation.

ManagementManagement

1.1. Perianal abscessPerianal abscess - superficial ones - superficial ones can be drained in office under L.Acan be drained in office under L.A

• IncisionIncision• Pus culture & sensitivityPus culture & sensitivity• Packing with iodophor gauge.Packing with iodophor gauge.• Laxative & Sitz bath.Laxative & Sitz bath.• Review & follow up 2-3 weeks to Review & follow up 2-3 weeks to

see for healing & fistula formation.see for healing & fistula formation.

ManagementManagement

• Organism culture is important.Organism culture is important.• Abscess with intestinal organisms have a Abscess with intestinal organisms have a

40% chance of forming fistula.40% chance of forming fistula.• Cultures growing Staphylococcus species Cultures growing Staphylococcus species

–Perianal skin infection and have no risk –Perianal skin infection and have no risk of subsequent fistula formation. of subsequent fistula formation.

2. 2. Ischiorectal abscessIschiorectal abscess - -• GAGA• Cruciate incision over max swelling.Cruciate incision over max swelling.

ManagementManagement

• Pus drained and culturedPus drained and cultured• Disrupt loculiDisrupt loculi• Drain placed.Drain placed.3. 3. Intersphincteric abscessIntersphincteric abscess - -• Transverse incision in anal canal Transverse incision in anal canal

below the dentate line, posteriorly.below the dentate line, posteriorly.• Abscess opened, leave drain, Abscess opened, leave drain,

prevents premature closure.prevents premature closure.

Management Management

4.4. Supralevator abscessSupralevator abscess - -• Location & etiology determines its Location & etiology determines its

drainage technique.drainage technique.• Evaluation with CT Scan & MRI .Evaluation with CT Scan & MRI .• Abdominal pathology –deal with causeAbdominal pathology –deal with cause• If extension of Ischiorectal –drainage If extension of Ischiorectal –drainage

through the space indicated.through the space indicated.• Anterior Supralevator are superficial and Anterior Supralevator are superficial and

more common in females.- transanal or more common in females.- transanal or transvaginal approach can be used.transvaginal approach can be used.

Anal fistula- “Fistula-in-ano”Anal fistula- “Fistula-in-ano”

Definition Definition --

• Hollow tract, lined with granulation Hollow tract, lined with granulation tissue connecting a primary opening tissue connecting a primary opening inside the anal canal to a secondary inside the anal canal to a secondary opening in the Perianal skin. opening in the Perianal skin.

• Treatment of fistula-in-ano can be Treatment of fistula-in-ano can be challenging. challenging.

Fistula-in-anoFistula-in-ano

• Magnitude of problem-Magnitude of problem- Prevalence rate - 8.6 / 100,000 Prevalence rate - 8.6 / 100,000

population.population.

• Male : Female = 2 : 1Male : Female = 2 : 1

• Mean age = 38 Years.Mean age = 38 Years.

EtiologyEtiology

* Following Anorectal abscess.* Following Anorectal abscess.

* * Other causesOther causes

- Sec. to trauma- Sec. to trauma

- Crohn’s disease- Crohn’s disease

- Anal fissures- Anal fissures

- Carcinoma- Carcinoma

- Radiation therapy- Radiation therapy

- Tuberculosis, Actinomycosis.- Tuberculosis, Actinomycosis.

PathophysiologyPathophysiology

Anal gland infection

Perianal abscessDrainage self/ surgery

Fistula formation

Clinical presentationClinical presentation

• HistoryHistory – Recurrent Swelling, – Recurrent Swelling, Discharge, Pain and Surgery for an Discharge, Pain and Surgery for an Abscess.Abscess.

• SymptomsSymptoms – –

- Perianal discharge - Pain- Perianal discharge - Pain

- Swelling - Bleeding- Swelling - Bleeding

- External opening- External opening

Clinical presentationClinical presentation

• Past medical history-Past medical history-

* Inflammatory bowel disease.* Inflammatory bowel disease.

* Diverticulitis* Diverticulitis

* Previous pelvic radiation * Previous pelvic radiation

* Tuberculosis* Tuberculosis

* Steroids therapy* Steroids therapy

* HIV infection* HIV infection

Clinical presentationsClinical presentations

• Physical examinationPhysical examination - -

* Look at entire perineum,* Look at entire perineum,

* An open sinus or elevation of granulation * An open sinus or elevation of granulation

tissue. tissue.

* Discharge may be seen.* Discharge may be seen.

* DRE- fibrous cord, or cord beneath the skin.* DRE- fibrous cord, or cord beneath the skin.

* Voluntary squeeze pressures & sphincter * Voluntary squeeze pressures & sphincter tone should be assessed.tone should be assessed.

Goodsall rule – Perianal Goodsall rule – Perianal fistulafistula• Transverse line drawn Transverse line drawn

across the anal vergeacross the anal verge• Anterior external Anterior external

opening associated opening associated with straight tract to with straight tract to anal canal or rectum.anal canal or rectum.

• Posterior ext. opening Posterior ext. opening follows curved tract, follows curved tract, entering posterior entering posterior midline.midline.

• Exception 3cmException 3cm

Park Classification system-Park Classification system-

A.A. Intersphincteric Intersphincteric

B.B. TranssphinctericTranssphincteric

C.C. SuprasphinctericSuprasphincteric

D.D. ExtrasphinctericExtrasphincteric

Fistula-in-anoFistula-in-ano

• Fistula with probeFistula with probe

Fistula-in-anoFistula-in-ano

A. A. IntersphinctericIntersphincteric - -

• Via internal Via internal sphincter to sphincter to intersphincteric intersphincteric space then to space then to perineum.perineum.

• 70%70%

B. B. TranssphinctericTranssphincteric - -

• Via internal and Via internal and external sphincter external sphincter into Ischiorectal into Ischiorectal fossa and then to fossa and then to perineum.perineum.

• 25%25%

Fistula-in-anoFistula-in-ano

• Transsphincteric Transsphincteric fistula.fistula.

Fistula-in-anoFistula-in-ano

C. C. SuprasphinctericSuprasphincteric – –

• Via intersphincteric Via intersphincteric space superiorly to space superiorly to above puborectalis above puborectalis muscle into muscle into Ischiorectal fossa Ischiorectal fossa then perineum.then perineum.

• 5%5%

D. D. ExtrasphinctericExtrasphincteric - -

• From Perianal skin From Perianal skin through levator ani through levator ani muscles to the muscles to the rectal wall rectal wall completely outside completely outside sphincter sphincter mechanism.mechanism.

• <1%<1%

Imaging StudiesImaging Studies

• Not indicated for routine evaluationNot indicated for routine evaluation

• Performed when external opening is Performed when external opening is difficult to identify, recurrent or multiple difficult to identify, recurrent or multiple fistulae.fistulae.

1.1. FistulographyFistulography--

- involves injection of contrast via the - involves injection of contrast via the opening and taking images in different opening and taking images in different planes.planes.

- 15- 48% accuracy.- 15- 48% accuracy.

Imaging studiesImaging studies

2. 2. Endo Anorectal Ultrasonography -Endo Anorectal Ultrasonography - - Transducer 7-10 MHz.- Transducer 7-10 MHz. - Installation of H2O2 can help location of - Installation of H2O2 can help location of

internal opening .internal opening . - not widely used.- not widely used.3. 3. MRIMRI - - - Study of choice - Study of choice - 80-90% concordance with oper.finding.- 80-90% concordance with oper.finding. - good for primary course and sec - good for primary course and sec

extensions.extensions.

Imaging Imaging 4. 4. CT ScanCT Scan – –

- Good for perirectal inflammation - Good for perirectal inflammation disease, delineating fluid pockets.disease, delineating fluid pockets.

- Needs oral and rectal contrast.- Needs oral and rectal contrast.

- poor delineation of muscular - poor delineation of muscular anatomy.anatomy.

5. 5. Barium enema / Small bowel seriesBarium enema / Small bowel series - -

- Useful in multiple fistulae or recurrent - Useful in multiple fistulae or recurrent disease, also to rule out IBD.disease, also to rule out IBD.

fistula imagingfistula imaging

• MRI showing MRI showing intersphincteric intersphincteric fistula anteriorlyfistula anteriorly

• Prm-puborectalis Prm-puborectalis muscle.muscle.

Other investigationsOther investigations

• Anal Manometry-Anal Manometry- Pressure evaluation of sphincter mechanism Pressure evaluation of sphincter mechanism

help in some cases -help in some cases - - Decreased tone in preop evaluation- Decreased tone in preop evaluation - previous fistulectomy- previous fistulectomy - obstetrical trauma- obstetrical trauma - high transsphincteric or suprasphincteric - high transsphincteric or suprasphincteric

fistulafistula - very elderly patient.- very elderly patient. If decreased, avoid - surgical division of any If decreased, avoid - surgical division of any

portion of sphincter.portion of sphincter.

Diagnostic proceduresDiagnostic procedures

A. A. E U A-E U A-

• Examination of perineum, DRE, anoscopy.Examination of perineum, DRE, anoscopy.

• To look for internal opening techniques-To look for internal opening techniques-

- Inject - H2O2, Milk, Dilute methylene blue- Inject - H2O2, Milk, Dilute methylene blue

- Traction on external opening may help- Traction on external opening may help

- Probing gently can help.- Probing gently can help.

B. B. Proctosigmodoscopy / Colonoscopy-Proctosigmodoscopy / Colonoscopy-

• Rigid sigmoidoscopy to rule rectal disease.Rigid sigmoidoscopy to rule rectal disease.

ManagementManagement 1. 1. Fistulotomy / Fistulectomy -Fistulotomy / Fistulectomy -

- laying open technique is useful in 85-95% of - laying open technique is useful in 85-95% of primary fistulae.primary fistulae.

- overlying skin, subcutaneous tissue, internal - overlying skin, subcutaneous tissue, internal sphincter divided with electrocautry, curette sphincter divided with electrocautry, curette tract to remove granulation tissue.tract to remove granulation tissue.

- complete fistulectomy creates bigger wound - complete fistulectomy creates bigger wound with no advantage in minimizing recurrence.with no advantage in minimizing recurrence.

- perform biopsy of firm or suggestive tissue.- perform biopsy of firm or suggestive tissue.

ManagementManagement

2. 2. Seton PlacementSeton Placement – – - Alone, in combination with fistulectomy or - Alone, in combination with fistulectomy or

as a stage procedure-as a stage procedure- Useful in –Useful in –• Complex fistulaeComplex fistulae• Recurrent fistulae after fistulectomyRecurrent fistulae after fistulectomy• Anterior fistulae in femalesAnterior fistulae in females• Poor preop sphincter pressure.Poor preop sphincter pressure.• Immunosuppresed patients. Immunosuppresed patients.

Seton placement-Seton placement-• Seton defines sphincter musclesSeton defines sphincter muscles

• Promotes - Drainage Promotes - Drainage

- Fibrosis.- Fibrosis.

• Material used-Material used-

- Silk suture- Silk suture

- Silastic vessel markers- Silastic vessel markers

- Rubber bands- Rubber bands

SetonSeton1.1. Single stage (cutting)Single stage (cutting)

• Passing seton through Passing seton through tract and tightened tract and tightened down with separate down with separate silk tie.silk tie.

• Fibrosis above Fibrosis above sphincter muscles sphincter muscles seen as it cuts the seen as it cuts the muscles.muscles.

• Tightened in office Tightened in office over weeksover weeks

2. 2. Two Stage (draining / Two Stage (draining / fibrosis)fibrosis)

• Pass seton through Pass seton through deep portion of external deep portion of external sphincter.sphincter.

• Seton left loose here.Seton left loose here.

• When superficial wound When superficial wound is healed , seton bound is healed , seton bound muscle is divided.muscle is divided.

• Studies support 2 stage Studies support 2 stage procedure using 0-procedure using 0-nylon.nylon.

3.Mucosal Advancement 3.Mucosal Advancement Flap -Flap -• In chronic high fistula , indication same as In chronic high fistula , indication same as

seton.seton.• Total fistulectomy , removal of primary and Total fistulectomy , removal of primary and

secondary tract with internal opening secondary tract with internal opening • Rectal mucomuscular flap is raised .Rectal mucomuscular flap is raised .• Internal muscle defect is closed with Internal muscle defect is closed with

absorbable suture and flap is sewn down absorbable suture and flap is sewn down over internal opening.over internal opening.

• Single stage procedureSingle stage procedure• Poor success in Acute infection and Poor success in Acute infection and

Crohn’s.Crohn’s.

Follow upFollow up

• Sitz bath Sitz bath

• AnalgesiaAnalgesia

• Stool bulk agents (bran)Stool bulk agents (bran)

• Frequent office visits to ensure Frequent office visits to ensure healing.healing.

• Healing in 6 weeks.Healing in 6 weeks.

ComplicationsComplications

EarlyEarly--

• Urinary retentionUrinary retention

• BleedingBleeding

• Fecal impactionFecal impaction

• Thrombosed Thrombosed hemorrhoids.hemorrhoids.

DelayedDelayed - -

• RecurrenceRecurrence

• Incontinence stool)Incontinence stool)

• Anal stenosisAnal stenosis

• Delayed wound Delayed wound healing.healing.

Outcome & PrognosisOutcome & PrognosisFollowingFollowing Rate of Rate of

RecurrenceRecurrenceIncontinence Incontinence of stoolof stool

Standard Standard

FistulotomyFistulotomy 0 -18%0 -18% 3 -7 %3 -7 %

SetonSeton 0 – 17%0 – 17% 0 -17 %0 -17 %

Mucosal Mucosal advancement advancement flapflap

1- 10%1- 10% 6 – 8%6 – 8%

Newer DevelopmentsNewer Developments

1.1. Biotechnical advances are Biotechnical advances are producing many new tissue producing many new tissue adhesives.adhesives.

- some reports suggest 60% success - some reports suggest 60% success with 1 year follow-up ,using fibrin with 1 year follow-up ,using fibrin glue in treatment of fistula-in-ano.glue in treatment of fistula-in-ano.

- less invasive & ↓ postop morbidity.- less invasive & ↓ postop morbidity.

Newer developmentsNewer developments

• Recurrent fistulous disease to rectum Recurrent fistulous disease to rectum and perineum with Anorectal sepsis – and perineum with Anorectal sepsis – indication for surgeryindication for surgery

• Recent reports suggest 50-60% Recent reports suggest 50-60% response rate with infiximab - the response rate with infiximab - the monoclonal antibody to TNFmonoclonal antibody to TNFαα for for Perianal fistulae.Perianal fistulae.

Thank you Thank you