The Management of Anorectal Abscess: An Inexpensive and Simple Alternative Technique to Incision and "Deroofing"

Transcription

1 The Management of Anorectal Abscess: An Inexpensive and Simple Alternative Technique to Incision and "Deroofing" William H. Isbister, MD; Stephen Kyle, MB From the Departments of Surgery, Wellington School of Medicine (Dr. Kyle), Wellington, New Zealand, and King Faisal Specialist Hospital and Research Centre (Dr. Isbister), Riyadh. Address reprint requests and correspondence to Dr. Isbister: Department of Surgery, King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadh 11211, Saudi Arabia. Accepted for publication 4 September All patients with anorectal abscess who were referred to the University Department of Surgery in Wellington have been managed by simple "de Pezzer" drainage since The catheter used was between 3 to 5 mm in diameter and was usually inserted under a local anesthetic. The method is described in detail. One hundred and fifty-seven patients have presented with anorectal abscess, and after exclusion of those patients with intersphincteric abscess, 140 have been managed using de Pezzer drainage. The male to female ratio was 2.7:1. A perianal abscess was present in 120 patients. General anesthesia was necessary in 23 patients, and 20 of these patients were admitted to the hospital. Thirteen patients were admitted for underlying medical problems. Three patients had Crohn's disease and five were diabetics. Seventy-four of the patients had symptoms that had lasted for 4 days or less, and 40 patients had antibiotics prescribed by their local practitioners. There was no past history of anorectal sepsis in 104 patients. Ninety-four of the catheters were removed in less than 15 days. Of the patients who were drained under local anesthetic only, eight said that the pain was so "intolerable" that they would opt for a general anesthesia in the future. Fifty-three patients returned to their normal activities or work within five days, and 107 were back at work 14 days after drainage. Three abscesses were inadequately drained. Fistulae developed in 37 patients within the followup period. The technique appears to be safe and reliable, is well tolerated by patients, and results in minimal hospitalization and an early return to work. WH Isbister, The Management of Anorectal Abscess: An Inexpensive and Simple Alternative Technique to Incision and "Deroofing". 1991; 11(4): Anorectal sepsis may arise from infection in either skin structures (i.e., hair follicles, sweat glands, sebaceous glands) or the anal glands themselves (i.e., cryptoglandular disease). If a cryptoglandular abscess is incised and retains its internal communication, a fistula-in-ano results. Over-aggressive management of fistula-in-ano may result in incapacitating anal incontinence. It is our view that over-aggressive management of the initial sepsis may result in

2 complex fistula formation and subsequently difficult fistula surgery. The danger to the mechanisms of continence in this event are obvious. The true incidence of complicated fistula-in-ano, and postoperative incontinence in the Kingdom of Saudi Arabia is unknown, but a larger number of complicated fistulae-in-ano have been seen during three months in the Kingdom (W.N.I.) than were encountered during the entire period of the study reported in this paper. This impression is confirmed by a report from Jeddah [1] of 200 cases of "recurrent fistula in ano" in which 139 were intersphincteric, 40 were transsphincteric and 21 (10.5%) were suprasphincteric or "high fistulae." The technique of de Pezzer catheter drainage of anorectal abscess was first described by Stuart in 1972 [2]. Since March 1981, we have used the method for all patients presenting with anorectal abscess to the University Department of Surgery in Wellington. In 1987 we reported our results with the technique in our first 97 patients presenting with anorectal abscess [3]. In this paper, we describe the technique in detail and update our results. Technique of Catheter Drainage Material and Methods Insertion of the catheter is usually performed under local anesthesia although some patients request a general anesthetic. With the patient in the left lateral position, and after administration of 10 mg of diazepam, a local anesthetic is injected into the skin overlying the point of maximum softening or fluctuation of the abscess (Figure 1). A small stab incision is made in the skin (3 4 mm in length) which must be just large enough to admit the cut-off mushroom of a self-retaining De Pezzer catheter (Figures 2, 3). The catheter is prepared by amputating the tip of the catheter through the side holes so that a funnel-shaped catheter results. This is folded and grasped in a small hemostat prior to insertion through the stab incision into the abscess cavity itself (Figure 4). The excess catheter is cut off so that only 10 mm protrudes above the skin surface (Figure 5). A dry dressing is applied to the perineum overlying the catheter and the patient is allowed to go home. Dressings are changed as necessary by the patient, the patient is reviewed after a week, and the catheter is removed at a second clinic visit a week later. Antibiotics are not administered and the patient's condition is reviewed a month following removal of the catheter. If drainage persists at this time, the patient is admitted to hospital for fistula surgery; otherwise, the patient is discharged. Figure 1. Injection of local anesthetic.

3 Figure 2. Stab incision at site of maximum fluctuation. Figure 3. Pus draining from stab site before drain inserted. Figure 4. "Cut off" catheter in hemostat about to be inserted into abscess cavity through stab incision.

4 Figure 5. "Cut off" catheter in situ prior to dressing. Results One hundred and fifty-seven patients with anorectal abscess have been treated by de Pezzer drainage in the 8 years between March 1981 and March Patient data were stored and analyzed on a microcomputer using software [4] written by one of the authors (W.H.I.). Of the 157 patients analyzed, 17 were found to have intersphincteric abscess and these patients were generally managed by endoanal drainage (Table 1). Of the remaining 140 patients who form the basis of this report, 102 were male and 38 were female, with mean ages of 39.7 and 39.5 years, respectively. A perianal abscess was present in the majority of patients (Table 1), but in three the type of abscess could not be determined. Fifteen patients required no sedation. General anesthesia was necessary in 23 patients and 20 of these patients were admitted to the hospital (Table 2). Thirteen patients were admitted to the hospital because of underlying medical problems and ten were admitted because of sepsis (Table 2). No particular occupational groups seemed to be more prone to anorectal abscess (Table 3). The majority of patients did not have any predisposing or associated diseases (Table 4), although three patients had Crohn's disease and five were diabetic. There was a past history of anorectal sepsis in 36 patients (Table 5). Over half of the patients had symptoms which had lasted for four days or less (Table 6), and 40 patients had antibiotics prescribed by their local practitioners (Table 7). Ninety-four of the catheters were removed in less than 15 days (Table 8). No catheter was used in one patient with a superficial perianal abscess. There was no difference in the complication rate between the patients in whom the drain "fell out" before the first clinic visit, and those in whom the drain was retained and removed deliberately. Table 1. Type of abscess. Type of abscess Perianal 120 Ischiorectal 17 Intersphincteric 17 Indeterminate 3

5 Table 2. Hospital admission. Hospital admission None (LA) 85 None (GA) immediate discharge 3 GA 1 day 12 GA 2 days 5 GA 3 days 3 Medical 1 day 8 Medical 2 days 2 Medical 3 days 3 For sedation recovery 9 For sepsis 10 GA = general anesthesia; LA = local anesthesia. Occupation Table 3. Patient occupation. Clerical 23 Professional 20 Retired 19 Manual worker 17 Housewife 17 Tradesperson 13 Skilled worker 13 Student 8 Salesperson 7 Other 3 Table 4. Associated diseases. Associated disease None 110 Diabetes 5 Crohn's disease 3 Other (unrelated) 22 Table 5. Previous anorectal sepsis. Previous sepsis None 104 Single abscess 15 2 abscesses 2 3 abscesses 2 > 3 abscesses 5 Previous fistula 5 Unknown 7

6 Table 6. Duration of symptoms. Duration of symptoms < 25 hr hr hr 0 2 days 21 3 days 22 4 days 26 5 days 18 6 days 17 > 7 days 31 Antibiotics Table 7. Use of antibiotics. None 85 Prescribed by general practitioner 40 Prescribed for patient toxicity 6 Prescribed for cellulitis 2 Other/unknown 7 Catheter removal Table 8. Duration of catheterization. < 7 days (accident) 39 9 days 9 11 days 7 13 days days days 4 19 days 6 21 days 3 > 21 days 5 No catheter 1 Of the patients who were drained under local anesthetic, 34 were unable to remember the procedure, 32 claimed that the procedure was painless and acceptable, and 26 had slight pain but said they would have their abscess managed in the same way again. Eight felt that the procedure was very painful but would prefer drainage under local anesthetic to general anesthetic, and eight said that the pain was "intolerable" and would refuse drainage under local anesthesia in the future. No patient complained about the presence of a perineal drain during the study. Fifty-three patients returned to their normal activities or work within five days of drainage and 107 were back at work fourteen days after drainage. Three abscesses were inadequately drained and were re-drained. Drainage continued after catheter removal, or further anorectal sepsis developed in 37 patients and these patients proceeded to fistula surgery. Follow-up varied from 12 months in the most recently drained patients to nine years in those patients treated during the first year of the study. Approximately 18 patients have been treated each year since the study commenced. Patients who suffered "intolerable" pain during the procedure were compared with all other patients who claimed the procedure to be "painless," "slightly painful but would have again," or "can't remember" (Table 9). "Intolerable" pain seemed to be more common in young women and was associated with a higher incidence of subsequent fistula development.

7 Table 9. Pain. No pain (N = 109) Pain (N = 8) General anesthesia (N = 23) Male: female ratio 2.9:1 1:1 2.8:1 Ischiorectal abscess 13/109 (11.9%) Subsequent fistula 24/109 (22.0%) 0/8 4/23 (17.4%) 4/8 9/23 (50%) (39%) Table 10. Subsequent fistula. No fistula (N = 103) Fistula (N = 37) Male: female ratio 3.7:1 2.7:1 Catheter removal (< 14 days) 71/103 (68.9%) Intolerable pain 4/103 ( 3.9%) Previous anorectal sepsis 36/103 (34.9%) Need for general anesthesia 13/103 (12.6%) 23/37 (62.1%) 4/37 (10.8%) 16/37 (43.2%) 10/37 (27%) Thirty-seven patients had fistulae develop following catheter drainage. Thirty-five of these patients originally had a perianal abscess. There seemed to be an association between the development of fistula and "intolerable" pain and a past history of anorectal sepsis. Fistula occurrence was more common in women (Table 10). The mean length of hospital stay was 0.57 days for abscess drainage and 3 days for laying open of fistula. Overall mean hospitalization, including time for fistula surgery, was 1.4 days. Discussion This simple technique is safe and reliable, is well tolerated by patients, and results in minimal hospitalization and an early return to work. An important aspect of the technique is that it provides immediate and continuing relief of symptoms. Pus is drained and skin closure is prevented until deep healing has taken place [2]. As soon as drainage is established, tension within the abscess decreases and symptoms are almost instantaneously relieved. Stuart [2] stresses that when the abscess is loculated the deep loculi will usually drain into the one in which the catheter is situated and this view is supported by the present study. This aspect of management is important because no accidental damage can be caused by "breaking down" loculi or probing in inappropriate directions. It is our contention that complicated fistulae may result from the latter unnecessary activities. It has never been necessary to drain a second loculus. Definitive fistula surgery was only required in 26.43% (95% C.I. = 19.4% 33.4%) of our patients, whereas in the 474 patients reported by Read and Abcarian [5], a fistulous opening was demonstrated in 34% (95% C.I. = 30% - 38%) of the patients. The difference in fistula rates just fails to reach significance, but as our numbers rise, the statistic improves! In further support of our thesis is the absence of any supralevator abscesses of fistulae in our series, although one might expect at least seven in a series of this size based on previously reported data [6]. It may be that the dangers of injudicious probing of the apex of an abscess cavity with "a curved 6-inch hemostat," in spite of the author's claims of the safety of the procedure, have been underestimated. The "high fistula" rate in Saudi patients is also high [1], and it may be that it too represents an over enthusiastic approach to the original anorectal sepsis. Stuart [2] describes "prolonged" catheter drainage of at least a month, but we have not found it necessary to retain the catheter for such a long period. No patient has needed fistula surgery if the catheter site was found to be completely healed six weeks after abscess drainage. Thirty-nine catheters were displaced accidentally because skin incisions were too large for the cut off catheter, but none needed to be replaced. Only 13 patients who were able to work remained off work for longer than fourteen days, but we have found a reluctance among New Zealand patients to return to their normal occupations when they had the excuse of "a drain

8 in situ"! It may be argued that the method is not acceptable by Saudis and other Muslims because of their religious obligations, but the technique has been used on four occasions in the Kingdom (W.H.I.), and so far no such problems or criticisms have been enountered! Operating room complications (1%) and postoperative complications (2%), although uncommon in Read and Abcarian's [5] series, were nonexistent in the present series. Read and Abcarian [5] concluded that their standardized method of treatment has proven to be safe and effective: the use of the operating room and regional anesthesia facilitating the establishment of adequate drainage, a beneficial by-product being the sparing of a second operation in 34% of patients in whom a fistula can be identified. In comparison with the present series, however, it could be argued that an avoidable average hospital stay of 5.7 days (1.4 days including stay for definitive fistula surgery in present study) and the not inconsequential hospital costs, a high incidence of supra levator fistulae, between 1 to 7 days packing, two or three weeks off work, and final wound healing at 4 to 12 weeks postoperatively compares somewhat unfavorably with the minimal hospitalization, lower persisting fistula rate, earlier return to work, and zero morbidity of the present series. It is time to re-examine the traditional approach to the management of anorectal abscess which involves the patient's emergency admission to hospital, general anesthesia, surgery in an operating theatre, and a period of hospital convalescence involving wound packing and delayed wound healing. It is suggested that the fundamental surgical principle of draining pus with the minimum of operative interference and tissue damage and the maintenance of adequate drainage by a self-retaining catheter is difficult to improve upon and is endorsed by the present study. The use of the technique in the Kingdom of Saudi Arabia may well result in lower rates of anorectal sepsis-related complicated disease. References 1. Jamjoom AMR. Fistula in ano: a review of 200 cases, a retrospective study. Ann Saudi Med 1989;9:625s. 2. Stuart M. Prolonged catheter drainage of anorectal abscess as a preliminary to elective fistulotomy. Med J Aust 1972;1: Isbister WH. A simple method for the management of anorectal abscess. Aust NZ J Surg 1987;57: Isbister WH. Microcomputers in surgery: a data file and analysis programme. Aust NZ J Surg 1983;53: Read DR, Abcarian H. A prospective study of 474 patients with anorectal abscess. Dis Colon Rectum 1979;22: Goligher JC. Surgery of the anus, rectum and colon, ed 5. London: Bailliere Tindall, 1984.