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Perianal abscess & Anal fistulae By Rajeev Suryavanshi Dept of General Surgery.

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Presentation on theme: "Perianal abscess & Anal fistulae By Rajeev Suryavanshi Dept of General Surgery."— Presentation transcript:

1 Perianal abscess & Anal fistulae By Rajeev Suryavanshi Dept of General Surgery.

2 Perianal abscess Definition - Infection of the soft tissue surrounding the anal canal, with formation of discrete abscess cavity. Infection of the soft tissue surrounding the anal canal, with formation of discrete abscess cavity. Often cavity is associated with fistulous tract. Often cavity is associated with fistulous tract.

3 Anorectal anatomy Rectum develops from hind gut at 6 weeks Rectum develops from hind gut at 6 weeks Anal canal formed at 8 weeks – ectoderm. Anal canal formed at 8 weeks – 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 verge. Anal canal – 4cm, pelvic diaphragm to anal verge.

4 Anatomy External Sphincter- - U shaped, continuation of levator ani - U shaped, continuation of levator ani - deep segment is continuous with puborectalis muscle and forms anorectal ring felt on DRE. - deep segment is continuous with puborectalis muscle and forms anorectal ring felt on DRE. - striated muscle - striated muscle - voluntary control - voluntary control - 3 components - sub mucous, superficial and deep. - 3 components - sub mucous, superficial and deep.

5 Anatomy- Internal sphincter- Internal sphincter- - smooth muscle - smooth muscle - autonomic control - autonomic control - extension of circular muscles of rectum. - extension of circular muscles of rectum. - contracted at rest. - contracted at rest.

6 Anatomy 4-8 anal glands drained by respective crypts, at dentate line. 4-8 anal glands drained by respective crypts, at dentate line. Gland body lies in intersphincteric plane. Gland body lies in intersphincteric plane. Anal gland function is lubrication. Anal gland function is lubrication. Columns of Morgagni Columns of Morgagni 8-14 long mucosal fold long mucosal fold.

7 Pathophysiology Infection starts in crypto glandular epithelium lining the anal canal. Infection starts in crypto glandular epithelium lining the anal canal. Internal anal sphincter a barrier to infection passing from gut to deep perirectal tissue. Internal anal sphincter a barrier to infection passing from gut to deep perirectal tissue. Duct of Anal gland penetrate internal sphincter into intersphincteric space. Duct of Anal gland penetrate internal sphincter into intersphincteric space. Once infection sets in intersphincteric space it can spread further. Once infection sets in intersphincteric space it can spread further.

8 Pathophysiology Infection & suppuration abscess formation Anal crypts obstruction Glandular secretion stasis

9 Frequency Common in 3 rd and 4 th decade of life Common in 3 rd and 4 th 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 spring. Increase incidence during summer and spring. Common in infants, poorly understood mechanism, fairly benign and majority settle with simple drainage. Common in infants, poorly understood mechanism, fairly benign and majority settle with simple drainage.

10 Etiology Abscess initially forms in the intersphincteric space and spreads along adjacent potential spaces. Abscess initially forms in the intersphincteric space and spreads along adjacent potential spaces. Common organisms- Common organisms- * E.Coli * E.Coli * Enterococcus species * Enterococcus species * Bacteroides species. * Bacteroides species.

11 Etiology Less common causes - Crohn’s Disease. Crohn’s Disease. Cancer. Cancer. Tuberculosis. Tuberculosis. Trauma. Trauma. Leukemia. Leukemia. Lymphoma. Lymphoma.

12 Clinical features Symptoms- Pain Perianal movement ↑ Pain Perianal movement ↑ pressure ↑ pressure ↑ Pruritis Pruritis Generally unwell. Generally unwell. Fever Fever Chill and rigor. Chill and rigor.Signs- Swelling Swelling Cellulitis Cellulitis induration induration Fluctuation Fluctuation Subcutaneous mass, near Perianal orifice. Subcutaneous mass, near Perianal orifice. DRE- fluctuation at times in ischorectal. DRE- fluctuation at times in ischorectal.

13 Classification of Anorectal abscesses Perianal 60% Perianal 60% Ischiorectal 20% Ischiorectal 20% Intersphincteric 5% Intersphincteric 5% Supralevator 4% Supralevator 4% Submucosal 1% Submucosal 1%

14 Classification Perianal – pus underneath skin of anal canal, do not traverse external sphincter. Perianal – pus underneath skin of anal canal, do not traverse external sphincter. Ischiorectal – suppuration traversing external sphincter into Ischiorectal space. Ischiorectal – suppuration traversing external sphincter into Ischiorectal space. Intersphincteric – suppuration between external and internal sphincter. Intersphincteric – suppuration between external and internal sphincter. Horse shoe abscess - uncommon circumferential infiltration of pus with in intersphincteric space. Horse shoe abscess - uncommon circumferential infiltration of pus with in intersphincteric space.

15 Investigation & Imaging No specific test required No specific test required Patients with diabetes, immunosuppresed will need lab evaluation. Patients with diabetes, immunosuppresed will need lab evaluation. Imaging – role in only deep seated, Supralevator or intersphincteric abscesses. Imaging – role in only deep seated, Supralevator or intersphincteric abscesses. CT Scan, MRI or Anal ultrasonography. CT Scan, MRI or Anal ultrasonography.

16 Management Mainly surgical Mainly surgical Antibiotics in diabetics & immunocompromised individuals. Antibiotics in diabetics & immunocompromised individuals. Early drainage is indicated as delay can cause- Early drainage is indicated as delay can cause- * prolong infection * prolong infection * tissue destruction ↑ * tissue destruction ↑ * chances of sphincter dysfunction ↑ * chances of sphincter dysfunction ↑ * Promote fistula formation. * Promote fistula formation.

17 Management 1. Perianal abscess - superficial ones can be drained in office under L.A Incision Incision Pus culture & sensitivity Pus culture & sensitivity Packing with iodophor gauge. Packing with iodophor gauge. Laxative & Sitz bath. Laxative & Sitz bath. Review & follow up 2-3 weeks to see for healing & fistula formation. Review & follow up 2-3 weeks to see for healing & fistula formation.

18 Management Organism culture is important. Organism culture is important. Abscess with intestinal organisms have a 40% chance of forming fistula. Abscess with intestinal organisms have a 40% chance of forming fistula. Cultures growing Staphylococcus species – Perianal skin infection and have no risk of subsequent fistula formation. Cultures growing Staphylococcus species – Perianal skin infection and have no risk of subsequent fistula formation. 2. Ischiorectal abscess - GA GA Cruciate incision over max swelling. Cruciate incision over max swelling.

19 Management Pus drained and cultured Pus drained and cultured Disrupt loculi Disrupt loculi Drain placed. Drain placed. 3. Intersphincteric abscess - Transverse incision in anal canal below the dentate line, posteriorly. Transverse incision in anal canal below the dentate line, posteriorly. Abscess opened, leave drain, prevents premature closure. Abscess opened, leave drain, prevents premature closure.

20 Management 4. Supralevator abscess - Location & etiology determines its drainage technique. Location & etiology determines its drainage technique. Evaluation with CT Scan & MRI. Evaluation with CT Scan & MRI. Abdominal pathology –deal with cause Abdominal pathology –deal with cause If extension of Ischiorectal –drainage through the space indicated. If extension of Ischiorectal –drainage through the space indicated. Anterior Supralevator are superficial and more common in females.- transanal or transvaginal approach can be used. Anterior Supralevator are superficial and more common in females.- transanal or transvaginal approach can be used.

21 Anal fistula- “Fistula-in-ano” Definition - Definition - Hollow tract, lined with granulation tissue connecting a primary opening inside the anal canal to a secondary opening in the Perianal skin. Hollow tract, lined with granulation tissue connecting a primary opening inside the anal canal to a secondary opening in the Perianal skin. Treatment of fistula-in-ano can be challenging. Treatment of fistula-in-ano can be challenging.

22 Fistula-in-ano Magnitude of problem- Magnitude of problem- Prevalence rate / 100,000 population. Prevalence rate / 100,000 population. Male : Female = 2 : 1 Male : Female = 2 : 1 Mean age = 38 Years. Mean age = 38 Years.

23 Etiology * Following Anorectal abscess. * Following Anorectal abscess. * Other causes * Other 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.

24 Pathophysiology Anal gland infection Perianal abscess Drainage self/ surgery Fistula formation

25 Clinical presentation History – Recurrent Swelling, Discharge, Pain and Surgery for an Abscess. History – Recurrent Swelling, Discharge, Pain and Surgery for an Abscess. Symptoms – Symptoms – - Perianal discharge - Pain - Perianal discharge - Pain - Swelling - Bleeding - Swelling - Bleeding - External opening - External opening

26 Clinical 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

27 Clinical presentations Physical examination - Physical 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 tone should be assessed. * Voluntary squeeze pressures & sphincter tone should be assessed.

28 Goodsall rule – Perianal fistula Transverse line drawn across the anal verge Transverse line drawn across the anal verge Anterior external opening associated with straight tract to anal canal or rectum. Anterior external opening associated with straight tract to anal canal or rectum. Posterior ext. opening follows curved tract, entering posterior midline. Posterior ext. opening follows curved tract, entering posterior midline. Exception 3cm Exception 3cm

29 Park Classification system- A. Intersphincteric B. Transsphincteric C. Suprasphincteric D. Extrasphincteric

30 Fistula-in-ano Fistula with probe Fistula with probe

31 Fistula-in-ano A. Intersphincteric - Via internal sphincter to intersphincteric space then to perineum. Via internal sphincter to intersphincteric space then to perineum. 70% 70% B. Transsphincteric - Via internal and external sphincter into Ischiorectal fossa and then to perineum. Via internal and external sphincter into Ischiorectal fossa and then to perineum. 25% 25%

32 Fistula-in-ano Transsphincteric fistula. Transsphincteric fistula.

33 Fistula-in-ano C. Suprasphincteric – Via intersphincteric space superiorly to above puborectalis muscle into Ischiorectal fossa then perineum. Via intersphincteric space superiorly to above puborectalis muscle into Ischiorectal fossa then perineum. 5% 5% D. Extrasphincteric - From Perianal skin through levator ani muscles to the rectal wall completely outside sphincter mechanism. From Perianal skin through levator ani muscles to the rectal wall completely outside sphincter mechanism. <1% <1%

34 Imaging Studies Not indicated for routine evaluation Not indicated for routine evaluation Performed when external opening is difficult to identify, recurrent or multiple fistulae. Performed when external opening is difficult to identify, recurrent or multiple fistulae. 1. Fistulography- - involves injection of contrast via the opening and taking images in different planes. - involves injection of contrast via the opening and taking images in different planes % accuracy % accuracy.

35 Imaging studies 2. Endo Anorectal Ultrasonography - - Transducer 7-10 MHz. - Transducer 7-10 MHz. - Installation of H2O2 can help location of internal opening. - Installation of H2O2 can help location of internal opening. - not widely used. - not widely used. 3. MRI - - Study of choice - Study of choice % concordance with oper.finding % concordance with oper.finding. - good for primary course and sec extensions. - good for primary course and sec extensions.

36 Imaging 4. CT Scan – - Good for perirectal inflammation disease, delineating fluid pockets. - Good for perirectal inflammation disease, delineating fluid pockets. - Needs oral and rectal contrast. - Needs oral and rectal contrast. - poor delineation of muscular anatomy. - poor delineation of muscular anatomy. 5. Barium enema / Small bowel series - 5. Barium enema / Small bowel series - - Useful in multiple fistulae or recurrent disease, also to rule out IBD. - Useful in multiple fistulae or recurrent disease, also to rule out IBD.

37 fistula imaging fistula imaging MRI showing intersphincteric fistula anteriorly MRI showing intersphincteric fistula anteriorly Prm-puborectalis muscle. Prm-puborectalis muscle.

38 Other investigations Anal Manometry- Anal Manometry- Pressure evaluation of sphincter mechanism help in some cases - Pressure evaluation of sphincter mechanism 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 fistula - high transsphincteric or suprasphincteric fistula - very elderly patient. - very elderly patient. If decreased, avoid - surgical division of any portion of sphincter. If decreased, avoid - surgical division of any portion of sphincter.

39 Diagnostic procedures A. E U A- 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. Proctosigmodoscopy / Colonoscopy- Rigid sigmoidoscopy to rule rectal disease. Rigid sigmoidoscopy to rule rectal disease.

40 Management 1. Fistulotomy / Fistulectomy - 1. Fistulotomy / Fistulectomy - - laying open technique is useful in 85-95% of primary fistulae. - laying open technique is useful in 85-95% of primary fistulae. - overlying skin, subcutaneous tissue, internal sphincter divided with electrocautry, curette tract to remove granulation tissue. - overlying skin, subcutaneous tissue, internal sphincter divided with electrocautry, curette tract to remove granulation tissue. - complete fistulectomy creates bigger wound with no advantage in minimizing recurrence. - complete fistulectomy creates bigger wound with no advantage in minimizing recurrence. - perform biopsy of firm or suggestive tissue. - perform biopsy of firm or suggestive tissue.

41 Management 2. Seton Placement – - Alone, in combination with fistulectomy or as a stage procedure- - Alone, in combination with fistulectomy or as a stage procedure- Useful in – Useful in – Complex fistulae Complex fistulae Recurrent fistulae after fistulectomy Recurrent fistulae after fistulectomy Anterior fistulae in females Anterior fistulae in females Poor preop sphincter pressure. Poor preop sphincter pressure. Immunosuppresed patients. Immunosuppresed patients.

42 Seton placement- Seton defines sphincter muscles Seton 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

43 Seton 1. Single stage (cutting) Passing seton through tract and tightened down with separate silk tie. Passing seton through tract and tightened down with separate silk tie. Fibrosis above sphincter muscles seen as it cuts the muscles. Fibrosis above sphincter muscles seen as it cuts the muscles. Tightened in office over weeks Tightened in office over weeks 2. Two Stage (draining / fibrosis) Pass seton through deep portion of external sphincter. Pass seton through deep portion of external sphincter. Seton left loose here. Seton left loose here. When superficial wound is healed, seton bound muscle is divided. When superficial wound is healed, seton bound muscle is divided. Studies support 2 stage procedure using 0-nylon. Studies support 2 stage procedure using 0-nylon.

44 3.Mucosal Advancement Flap - In chronic high fistula, indication same as seton. In chronic high fistula, indication same as seton. Total fistulectomy, removal of primary and secondary tract with internal opening Total fistulectomy, removal of primary and secondary tract with internal opening Rectal mucomuscular flap is raised. Rectal mucomuscular flap is raised. Internal muscle defect is closed with absorbable suture and flap is sewn down over internal opening. Internal muscle defect is closed with absorbable suture and flap is sewn down over internal opening. Single stage procedure Single stage procedure Poor success in Acute infection and Crohn’s. Poor success in Acute infection and Crohn’s.

45 Follow up Sitz bath Sitz bath Analgesia Analgesia Stool bulk agents (bran) Stool bulk agents (bran) Frequent office visits to ensure healing. Frequent office visits to ensure healing. Healing in 6 weeks. Healing in 6 weeks.

46 Complications Early- Urinary retention Urinary retention Bleeding Bleeding Fecal impaction Fecal impaction Thrombosed hemorrhoids. Thrombosed hemorrhoids. Delayed - Recurrence Recurrence Incontinence stool) Incontinence stool) Anal stenosis Anal stenosis Delayed wound healing. Delayed wound healing.

47 Outcome & Prognosis Following Rate of Recurrence Incontinence of stool StandardFistulotomy 0 -18% 0 -18% 3 -7 % 3 -7 % Seton 0 – 17% 0 – 17% % % Mucosal advancement flap 1- 10% 1- 10% 6 – 8% 6 – 8%

48 Newer Developments 1. Biotechnical advances are producing many new tissue adhesives. - some reports suggest 60% success with 1 year follow-up,using fibrin glue in treatment of fistula-in-ano. - some reports suggest 60% success with 1 year follow-up,using fibrin glue in treatment of fistula-in-ano. - less invasive & ↓ postop morbidity. - less invasive & ↓ postop morbidity.

49 Newer developments Recurrent fistulous disease to rectum and perineum with Anorectal sepsis – indication for surgery Recurrent fistulous disease to rectum and perineum with Anorectal sepsis – indication for surgery Recent reports suggest 50-60% response rate with infiximab - the monoclonal antibody to TNFα for Perianal fistulae. Recent reports suggest 50-60% response rate with infiximab - the monoclonal antibody to TNFα for Perianal fistulae.

50 Thank you


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