Anorectal Abscess and Fistula. Brian P. Bosworth, MD, NYSGEF Assistant Professor of Medicine Weill Cornell Medical College

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1 Anorectal Abscess and Fistula Brian P. Bosworth, MD, NYSGEF Assistant Professor of Medicine Weill Cornell Medical College

2 Definitions Manifestation of the same process Anorectal abscess : acute Fistula-in-ano : chronic

3 Etiology Cryptoglandular Crohn s / UC Hidradenitis Carcinoma Radiation Trauma / Foreign body Lymphoma TB Actinomycosis LGV PID Post-surgery Hemorrhoidectomy Prostatic Surgery Episiotomy

4 Cryptoglandular Infection Infection of anal glands? Cryptoglandular theory first described by Chiari in 1878 Internal Os is found at dentate line 70-90% of pathologic specimens may demonstrate infected anal glands

5 Avenues of Extension

6 4 Classifications of Abscess They are not all perirectal abscesses!!! Perianal Ischioanal Intersphincteric Supralevator

7 Treatment of Perianal Abscess How do you drain it? Mushroom catheter Cruciate incision Packing? Where do you place the incision?

8 Antibiotics Probably unnecessary for simple abscesses Use if: Immunocompromised Diabetic Valvular heart disease Cellulitis

9 Post-op care Sitz baths Regular diet Bulk forming agents Follow up 2 weeks to remove drain

10 I & D of Abscess What are the results of drainage alone? Vasilevsky, Gordon (DCR 1984) Recurrent abscess: 11% Fistula: 37% Scoma, Salvati (DCR 1974) 66% developed fistula In general, about 50% (up to 70%?) develop fistula

11 Intersphincteric Abscess Diagnosis often missed EUA Treatment: Lay open abscess

12 Supralevator Abscess Rare Most patients have pelvic inflammatory condition Crohn s, PID, Diverticulitis May also be cephalad extension of inter- or trans-sphincteric abscess

13 Supralevator Abscess Avoid high extrasphincteric fistula

14 Supralevator Abscess

15 Supralevator Abscess Transrectal Transvaginal

16 Horseshoe Abscess Pus extends bilaterally from a (usually) posterior source Trans-sphincteric or Inter-sphincteric plane

17 Horseshoe Abscess Deep Post-anal Space

18 Endoanal U/S Cho (DCR 1999) 1) Intersphincteric tract 2) Internal Sphincter defect 3) Subepithelial breach With all 3 findings: 94% Sensitivity 87% Specificity Choen (Br J S 1991) Digital exam vs. U/S No signif difference for inter- and transsphincteric fistulas U/S no help in supraor extra-sphincteric fistulas

19 Endoanal U/S Deen (Gut 1994) 18 pts with complex anal fistulas Evaluated with U/S and compared with Exam In 17 pts U/S accurate CCF Florida Endoanal U/S Accurate for internal opening and fistula tract in 24 of 28 pts. Injection with H 2 O 2 increased yeald of study by 24% for fistula tract, 28% for internal opening

20 MRI Lunnis (DCR 1994) MRI vs. U/S MRI: 85.7% accurate for tract 80% accurate for internal opening More accurate than U/S in complex tracts+ Orsoni (Br J S 1999) 22 pts with Crohn s MRI vs. U/S U/S more accurate than MRI in detecting anorectal abscess complicating CD

21 MRI Beckingham (Br J S 1996) Dynamic Contrast Enhanced MRI (DCMRI) Sensitivity 97% Specificity 100% In detecting fistulas

22 Park s Classification of Fistulas Intersphincteric Transsphincteric Suprasphincteric Extrasphincteric

23 Park s Classification Intersphincteric Transsphincteric

24 Park s Classification Suprasphincteric Extrasphincteric

25 Treatment Options Fistulotomy Fistulectomy Seton Cutting Draining Future Endoanal advancement flap Fibrin Glue

26 Primary Fistulotomy Should you do it? Controversial Pros High rate of fistula with I&D alone Lowers rate of recurrence from unrecognized internal os Cons Perform fistulotomy unnecessarily in some patients Difficult to find internal opening in inflammation (false passage)

27 Primary Fistulotomy Mc Elwain (DCR 1975) Recurrence rate 3.6% after 1 fistulotomy Read, Abcarian (DCR 1979) Important to look for internal os Failed to identify internal os in 66% Schouten, van Vroonhoven (DCR 1991) Randomized 70 pts 1 fistulotomy vs. I&D Median F/U 42 mths Recurrence: 2.9% vs. 40.6% Incontincence: 39.4% vs. 21.4%

28 Fistulotomy

29 How much muscle can you divide? It depends on the patient!!! Lower ½ of the IAS, in some patients Posteriorly, the whole IAS and most of the EAS be cut if PR spared, in some patients Rates of incontinence after fistulotomy 10 50% In general, the more muscle you cut, the higher risk of incontinence

30 Incontincence after Fistulotomy Parks and Stitz Intersphincteric: 17% Transsphincteric: 1/3 Vasilevsky and Gordon 6% incontinence Sainio and Husa Minor incontinence in 34% Watch out in: Women Elderly Complex fistulas Crohn s fistulas Multiple fistulas

31 Seton

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