{ "slug": "how-to-prevent-fistula", "question": "How can you prevent an anal fistula from forming?", "shortTitle": "Preventing Anal Fistula After Abscess", "clinicalQuestion": "In patients with an anorectal (perianal) abscess, what treatments or practices at the time of abscess drainage reduce the subsequent risk of developing anal fistula (fistula-in-ano) or having it recur?", "questionKind": "options", "pico": { "population": "Adults and children with an anorectal or perianal abscess, particularly after incision and drainage", "intervention": "Measures intended to prevent fistula formation, such as primary fistulotomy or seton placement at time of drainage, antibiotic use, wound packing practices, or other adjunct techniques", "comparator": "Standard incision and drainage alone without the additional preventive measure", "outcomes": [ "Incidence of fistula-in-ano formation after abscess drainage", "Fistula recurrence rate", "Abscess recurrence rate", "Need for repeat surgery", "Wound healing time", "Fecal incontinence or other complication rates" ], "excludes": [] }, "category": "anorectal", "relatedConditions": [ "anal-fistula", "anorectal-abscess", "perianal-abscess" ], "relatedTreatments": [], "relatedEvidence": [], "bottomLine": { "verdict": "No treatment reliably stops a fistula from forming after an abscess is drained, and antibiotics are not a safe bet for prevention.", "detail": "Six randomised trials have tested different approaches at the time of abscess drainage, and they disagree with each other. The clearest conflict is over antibiotics: one trial found they lowered fistula rates, but a separate, well-conducted placebo-controlled trial found they were linked to more fistulas, not fewer. The most consistent benefit across trials came from treating a fistula tract surgically at the same time as draining the abscess, when one is already visible.", "studyIds": [ "pmid:41035902", "pmid:35929816", "pmid:33447866", "pmid:31054551", "pmid:28822559", "pmid:21730779", "pmid:20614450" ] }, "strength": { "level": "moderate", "why": "6 well-conducted randomised trials address this question directly. The studies disagree with one another, so the overall certainty is lower than any single one of them.", "override": null }, "direction": { "level": "harm-signal", "why": "A well-conducted study in people reported harm.", "override": null, "signOff": null, "withheld": null }, "counts": { "recordsRetrieved": 140, "recordsScreened": 139, "included": 73, "rcts": 6, "systematicReviews": 8, "observational": 36, "participants": 19128, "yearFrom": 1980, "yearTo": 2026, "registeredTrialsWithoutResults": 0, "direct": 28 }, "excluded": [], "outcomes": [ { "name": "Fistula formation after abscess drainage", "status": "insufficient", "note": "Trials disagree sharply. One trial found fewer fistulas with antibiotics after drainage, but a separate, placebo-controlled trial found more fistulas in the antibiotic group. No single method is consistently proven to lower this risk.", "studyIds": [ "pmid:28822559", "pmid:21730779" ] }, { "name": "Recurrence when a visible fistula is treated during the same abscess operation", "status": "possible-improvement", "note": "A randomised trial found a sphincter-sparing seton technique done at the time of abscess drainage raised the share of patients with complete healing and no fistula from 41% to 78%, compared with drainage alone. A review of similar trials found fewer repeat surgeries when the fistula tract was treated at the same time, without a clear rise in bowel control problems.", "studyIds": [ "pmid:41035902", "pmid:20614450" ] }, { "name": "Abscess coming back (recurrence)", "status": "insufficient", "note": "A trial comparing needle aspiration with surgical incision and drainage found more recurrences after aspiration (41%) than after incision and drainage (15%), a statistically significant difference. No study in this set reported whether packing the wound after drainage changes the chance of abscess recurrence.", "studyIds": [ "pmid:33447866" ] }, { "name": "Need for repeat surgery", "status": "possible-improvement", "note": "A review of trials found that treating the fistula tract at the same time as draining the abscess reduced the chance of needing repeat surgery, compared with draining the abscess alone.", "studyIds": [ "pmid:20614450" ] }, { "name": "Wound healing time and post-operative pain", "status": "possible-improvement", "note": "One trial found not packing the wound caused less pain than packing it, with no difference in fistula or recurrence rates. Another small trial found a negative-pressure suction device sped healing and lowered pain compared with standard gauze dressing.", "studyIds": [ "pmid:35929816", "pmid:31054551" ] }, { "name": "Fecal incontinence or bowel control problems", "status": "insufficient", "note": "One trial that added fistula surgery to abscess drainage found no statistically significant difference in incontinence (loss of bowel control) at one year compared with drainage alone, but the number of incontinence events was small, so a real difference could have been missed. No study in this set reported detailed anal-function testing after sphincter-sparing procedures, so it is not clear whether milder or delayed continence problems were captured.", "studyIds": [ "pmid:20614450" ] }, { "name": "Whether antibiotics after drainage prevent fistula", "status": "possible-harm", "note": "The best-designed trial here - randomised, placebo-controlled and double-blind - found more fistulas in people given antibiotics after drainage (37%) than those given placebo (22%). A different, lower-quality trial found the opposite. Because the strongest trial points toward harm, antibiotics should not be assumed to prevent fistula.", "studyIds": [ "pmid:21730779", "pmid:28822559" ] } ], "benefits": [ { "text": "When a fistula tract is already visible at the time the abscess is drained, treating it then - for example with a seton, a thin surgical thread left in the tract - lowered later fistula and recurrence rates compared with draining the abscess alone, in a randomised trial and a review of similar trials.", "studyIds": [ "pmid:41035902", "pmid:20614450" ] }, { "text": "Leaving the wound unpacked after drainage caused less pain than packing it, without making fistula or recurrence more likely, in a randomised trial.", "studyIds": [ "pmid:35929816" ] }, { "text": "A small randomised trial found a negative-pressure suction device used after drainage lowered fistula and recurrence rates and sped healing compared with standard gauze dressing changes, though this needs confirming in larger trials.", "studyIds": [ "pmid:31054551" ] } ], "limitations": [ { "text": "The randomised trials disagree with each other, especially on antibiotics - one found benefit, another found harm. This conflict is the main reason certainty here is only moderate, not high.", "studyIds": [ "pmid:28822559", "pmid:21730779" ] }, { "text": "Most of the available evidence is retrospective, comparing groups that were not randomly assigned, so differences between groups rather than the treatment itself could explain some results.", "studyIds": [ "pmid:42321429", "pmid:42132969", "pmid:41047078", "pmid:41019154", "pmid:39649212" ] }, { "text": "Several of the randomised trials followed people for only weeks to a few months, which may be too short to catch fistulas that form later.", "studyIds": [ "pmid:35929816", "pmid:33447866", "pmid:31054551" ] }, { "text": "Many studies combine children and adults, or look only at infants, whose abscesses and healing may behave differently from adults.", "studyIds": [ "pmid:40983150", "pmid:40585484", "pmid:39693822", "pmid:36894443" ] } ], "risks": [ { "text": "In a rigorous placebo-controlled trial, people given antibiotics after drainage developed fistulas more often than those given placebo (37% vs 22%).", "studyIds": [ "pmid:21730779" ], "severity": "serious" }, { "text": "Needle aspiration of the abscess, instead of surgical incision, was linked to more abscesses coming back in one trial (41% vs 15%).", "studyIds": [ "pmid:33447866" ], "severity": "minor" }, { "text": "Packing the wound after drainage caused more pain than leaving it unpacked, with no added benefit in preventing fistula or recurrence.", "studyIds": [ "pmid:35929816" ], "severity": "minor" } ], "whyPeopleTryIt": [ { "text": "Antibiotics feel like a natural safeguard after any infection is drained, even though trials disagree about whether they actually help here." }, { "text": "Packing the wound or doing sitz baths feels like active self-care, giving people something to do during a slow, uncomfortable healing process." }, { "text": "People want to avoid a second operation, so techniques done right away, like a seton, can feel like insurance against needing more surgery later." }, { "text": "A less invasive option, like needle aspiration instead of a surgical cut, can feel appealing because it sounds gentler, even though it was less effective in a trial." } ], "keyStudies": [ "pmid:21730779", "pmid:28822559", "pmid:20614450", "pmid:41035902", "pmid:33447866", "pmid:35929816", "pmid:31054551" ], "studies": [ { "id": "pmid:42500525", "pmid": "42500525", "doi": "10.3389/fmed.2026.1865558", "nctId": null, "pmcid": "PMC13395717", "title": "Sphincter-induced dynamic obstruction in a synthetic intersphincteric anal fistula model: a proof-of-concept fluid-structure interaction study", "firstAuthor": "Yu", "multipleAuthors": false, "journal": "Front Med (Lausanne)", "year": 2026, "design": "lab", "n": null, "nField": "not-reported", "population": "a model built from MRI of a healthy volunteer, used to simulate an anal fistula tract", "intervention": "simulated contraction of the anal sphincter muscle around a synthetic fistula tract", "comparator": "no comparator group; different stages of the simulated contraction were compared", "primaryOutcome": "fluid flow speed inside the fistula tract, looking for areas where fluid gets stuck", "result": "sphincter contraction created large areas of very slow fluid movement even though the tract itself stayed open", "resultDirection": "harm", "quality": "very-low", "qualityWhy": "this is a computer simulation based on one healthy volunteer's anatomy with an artificial fistula, not a real patient or clinical test, so it cannot show whether this actually causes or prevents fistulas.", "directness": "indirect", "relevanceNote": "", "limitations": "the abstract states this is a synthetic model in a healthy volunteer, described as 'qualitative proof-of-concept evidence pending validation in patient-specific native fistula models and clinical studies'", "followUp": "", "plainFinding": "Muscle squeezing may trap fistula fluid", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42500525/", "sourceText": "INTRODUCTION: Perianal abscess often progresses to anal fistula despite timely drainage, and recurrence remains common after sphincter-preserving surgery. Although inadequate drainage is a key factor, existing explanations focus mainly on anatomy, while the role of anal sphincter activity is unclear. This study examined whether sphincter contraction impairs intraluminal flow and contributes to drainage failure. METHODS: A subject-specific fluid-structure interaction model was constructed from high-resolution pelvic MRI. A three-dimensional finite element model of the anal sphincter complex with a synthetic intersphincteric fistula tract was reconstructed. Time-dependent physiological loading simulated sphincter contraction, and bidirectional analyses were performed. Intraluminal velocity fields were quantified using an image-based inverse mapping approach to characterize low-velocity retention zones. RESULTS: Sphincter contraction induced extensive low-velocity regions despite anatomical patency, with a progressive increase during mid-loading. Connectivity analysis revealed an aggregation-retention-fragmentation cycle, and multi-threshold sensitivity analysis supported the robustness of low-velocity region identification. CONCLUSION: In this healthy-volunteer-derived, synthetic intersphincteric fistula model, sphincter contraction generated low-velocity retention zones despite preserved anatomical patency. These findings support a plausible biomechanical hypothesis for ineffective fistula drainage, but should be interpreted as qualitative proof-of-concept evidence pending validation in patient-specific native fistula models and clinical studies.", "provenance": [ { "field": "population", "quote": "A subject-specific fluid-structure interaction model was constructed from high-resolution pelvic MRI." }, { "field": "population", "quote": "healthy-volunteer-derived, synthetic intersphincteric fistula model" }, { "field": "intervention", "quote": "Time-dependent physiological loading simulated sphincter contraction, and bidirectional analyses were performed." }, { "field": "comparator", "quote": "RESULTS: Sphincter contraction induced extensive low-velocity regions despite anatomical patency, with a progressive increase during mid-loading." }, { "field": "primaryOutcome", "quote": "Intraluminal velocity fields were quantified using an image-based inverse mapping approach to characterize low-velocity retention zones." }, { "field": "result", "quote": "Sphincter contraction induced extensive low-velocity regions despite anatomical patency, with a progressive increase during mid-loading." }, { "field": "result", "quote": "these findings support a plausible biomechanical hypothesis for ineffective fistula drainage, but should be interpreted as qualitative proof-of-concept evidence pending validation in patient-specific native fistula models and clinical studies." } ] }, { "id": "pmid:42321429", "pmid": "42321429", "doi": "10.1038/s41598-026-59144-z", "nctId": null, "pmcid": "PMC13304137", "title": "Comparison of incision and drainage procedure with drainage and ligation of the intersphincteric fistula tract in the treatment of deep perianal abscess", "firstAuthor": "Akay", "multipleAuthors": true, "journal": "Sci Rep", "year": 2026, "design": "retrospective", "n": 111, "nField": "reported", "population": "patients with deep perianal abscess and transsphincteric fistula", "intervention": "incision and drainage combined with LIFT (ligation of intersphincteric fistula tract) procedure", "comparator": "incision and drainage alone", "primaryOutcome": "persistent fistula at 6 months confirmed by exam and MRI", "result": "persistent fistula occurred in 38.2% of drainage-only patients versus 5.7% of drainage-plus-LIFT patients at 6 months", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This is a retrospective, non-randomized comparison, so differences between groups could explain the results rather than the treatment itself.", "directness": "direct", "relevanceNote": "", "limitations": "non-randomized design; authors state findings require confirmation through prospective randomized controlled trials", "followUp": "6 months", "plainFinding": "Fewer fistulas with added LIFT procedure", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42321429/", "sourceText": "Patients with deep perianal abscess (DPA) and transsphincteric fistula typically require incision and drainage as emergency treatment. However, recurrent abscesses and fistulas are common. This study aimed to evaluate the impact of simultaneous ligation of the intersphincteric fistula tract (LIFT) on abscess recurrence, incontinence, and fistula healing. This study is a retrospective analysis of an institutional protocol and includes 111 patients divided into two groups: Group I (incision and drainage alone, n = 57) and Group II (incision and drainage combined with the LIFT procedure, n = 54). The primary endpoint was persistent fistula at 6 months, confirmed by clinical examination and magnetic resonance imaging (MRI). Secondary endpoints included abscess recurrence, Wexner incontinence score changes, and complications. Firth's penalized logistic regression, inverse probability of treatment weighting (IPTW), and log-rank analyses were performed to assess outcomes. At the 3rd month, the number of patients with persistent fistula was 16 (28.1%) in Group I, while it was 3 patients (5.6%) in Group II (P = 0.002). At the 6th month, persistent fistula was observed in 21 of 55 patients (38.2%) in Group I and 3 of 53 patients (5.7%) in Group II (P < 0.001). Firth's penalized logistic regression showed that the LIFT procedure was significantly associated with reduced fistula persistence (OR = 0.079, 95% CI 0.019-0.327, P < 0.001). A sensitivity analysis restricted to patients with MRI-confirmed transsphincteric fistula (Group I: n = 34; Group II: n = 54) confirmed these findings (59.4% vs. 5.7%, P < 0.001). IPTW-adjusted analysis yielded consistent results (weighted OR = 0.063). This study demonstrates that the LIFT procedure, when applied together with drainage, reduces the incidence of persistent fistula and shows a non-significant reduction in abscess recurrence in patients with DPA and complex anal fistula. These findings should be interpreted with caution due to the non-randomized design and require confirmation through prospective randomized controlled trials.", "provenance": [ { "field": "population", "quote": "Patients with deep perianal abscess (DPA) and transsphincteric fistula" }, { "field": "intervention", "quote": "incision and drainage combined with the LIFT procedure" }, { "field": "comparator", "quote": "incision and drainage alone" }, { "field": "primaryOutcome", "quote": "The primary endpoint was persistent fistula at 6 months, confirmed by clinical examination and magnetic resonance imaging (MRI)" }, { "field": "result", "quote": "At the 6th month, persistent fistula was observed in 21 of 55 patients (38.2%) in Group I and 3 of 53 patients (5.7%) in Group II (P < 0.001)" }, { "field": "n", "quote": "includes 111 patients divided into two groups: Group I (incision and drainage alone, n = 57) and Group II (incision and drainage combined with the LIFT procedure, n = 54)" }, { "field": "limitations", "quote": "These findings should be interpreted with caution due to the non-randomized design and require confirmation through prospective randomized controlled trials." } ] }, { "id": "pmid:42221001", "pmid": "42221001", "doi": "10.3389/fped.2026.1789225", "nctId": null, "pmcid": "PMC13219376", "title": "Age-stratified management of pediatric perianal abscesses: a proposed framework integrating the \"Developmental Healing Axis\"", "firstAuthor": "Yuan", "multipleAuthors": true, "journal": "Front Pediatr", "year": 2026, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "children with perianal abscesses", "intervention": "age-specific management (antibiotics/observation in infants, surgery considered in older children)", "comparator": "surgical incision and drainage versus conservative treatment", "primaryOutcome": "fistula formation and recurrence", "result": "Surgical drainage may raise fistula risk, especially in older children, while conservative treatment often works well in infants", "resultDirection": "mixed", "quality": "very-low", "qualityWhy": "This is a narrative review summarizing other studies and opinions, not new controlled data, so it can't reliably prove what prevents fistulas.", "directness": "indirect", "relevanceNote": "", "limitations": "Narrative review without stated systematic methodology, no original patient data, numbers, or statistical results reported; identifies gaps and calls for more research.", "followUp": "", "plainFinding": "Gentler treatment in infants may lower fistula risk", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42221001/", "sourceText": "Pediatric perianal abscesses represent a frequent yet underrecognized condition that poses diagnostic and therapeutic challenges due to tissue fragility and age-dependent healing dynamics. This review synthesizes current evidence on the epidemiology, pathophysiology, and management of pediatric perianal abscesses to provide a conceptual basis for clinical decision-making. Surgical interventions such as incision and drainage offer rapid symptom relief but may increase the risk of fistula formation, particularly in older children. In contrast, conservative strategies including antibiotic therapy and observation are often effective in infants and young children, reflecting their superior regenerative capacity. Age-related differences in immune response, microbiota composition, and glandular anatomy contribute to variations in disease progression and healing outcomes. By integrating data from recent studies and clinical guidelines, this review highlights the importance of individualized, age-specific management to optimize recovery, minimize recurrence, and prevent fistula development. Furthermore, it identifies gaps in current evidence and underscores the need for standardized treatment protocols and future research into predictive and microbiome-related factors influencing disease course.", "provenance": [ { "field": "population", "quote": "Pediatric perianal abscesses represent a frequent yet underrecognized condition" }, { "field": "intervention", "quote": "conservative strategies including antibiotic therapy and observation are often effective in infants and young children" }, { "field": "comparator", "quote": "Surgical interventions such as incision and drainage offer rapid symptom relief but may increase the risk of fistula formation" }, { "field": "primaryOutcome", "quote": "minimize recurrence, and prevent fistula development" }, { "field": "result", "quote": "Surgical interventions such as incision and drainage offer rapid symptom relief but may increase the risk of fistula formation, particularly in older children. In contrast, conservative strategies including antibiotic therapy and observation are often effective in infants and young children" } ] }, { "id": "pmid:42132969", "pmid": "42132969", "doi": "10.1007/s10151-025-03244-x", "nctId": null, "pmcid": "PMC13364938", "title": "Three-cavity clearance significantly reduces the postoperative fistula rate and abscess recurrence following glandular perianal abscess: a single-center real-world study", "firstAuthor": "Xuan", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2026, "design": "case-series", "n": 308, "nField": "reported", "population": "patients who had surgery for perianal abscesses caused by infected anal glands", "intervention": "a surgical technique called three-cavity clearance (TCC)", "comparator": "", "primaryOutcome": "whether an anal fistula formed or the abscess came back after surgery", "result": "4.9% developed a fistula afterward and 8.1% had the abscess come back, with an overall treatment success rate of 87.0%", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This is a single-center case series looking back at one group of patients with no comparison group, so it can't show whether this technique is better than other treatments.", "directness": "direct", "relevanceNote": "", "limitations": "Single-center, retrospective design with no comparator group, relying on risk-factor modeling rather than a controlled trial.", "followUp": "37.9 ± 16.8 months", "plainFinding": "Low fistula and recurrence rates after surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42132969/", "sourceText": "OBJECTIVE: The aim of this study was to further analyze the efficacy and safety of three-cavity clearance (TCC) in the treatment of glandular perianal abscesses, explore the risk factors for postoperative anal fistula and perianal abscess recurrence, and build a prediction model to increase the success rate of TCC in treating perianal abscesses. METHODS: Clinical data were collected from patients who underwent TCC at the Second Affiliated Hospital of Nanjing University of Chinese Medicine from January 2018 to January 2024. Risk factors for perianal abscess recurrence and anal fistula after TCC were analyzed using univariate and multivariate logistic regression. A predictive nomogram model was established on the basis of independent risk factors, and its predictive performance was evaluated. Additionally, risk function curves were used for postoperative anal fistula and abscess recurrence across different abscess locations with statistical significance assessed via log-rank tests. RESULTS: A total of 308 patients were included from January 2018 to January 2024, with an average follow-up time of 37.9 ± 16.8 months. The postoperative fistula rate was 4.9%, and the abscess recurrence rate was 8.1%. One patient reported occasional fluid leakage after the operation, with a Wexner score of 1 point. The total success rate was 87.0%. Logistic regression analysis revealed that the abscess site, combined diabetes, nutritional status and history of abscess surgery were risk factors for recurrence and anal fistula formation after TCC (p < 0.05). The area under the receiver-operating characteristic curve (ROC) curve was 0.889 (95% CI 0.82-0.95), and the specificity and sensitivity were 95.5% and 75%, respectively. CONCLUSIONS: TCC for perianal abscess can significantly increase the success rate of treatment and reduce the postoperative fistula rate and abscess recurrence. The abscess site, combined diabetes, nutritional status, and history of abscess surgery are independent risk factors for fistula and abscess recurrence after TCC. Current research implies that TCC is a safe and effective surgery for perianal abscess and is worthy of further study and application.", "provenance": [ { "field": "n", "quote": "A total of 308 patients were included from January 2018 to January 2024" }, { "field": "population", "quote": "glandular perianal abscesses" }, { "field": "intervention", "quote": "three-cavity clearance (TCC)" }, { "field": "primaryOutcome", "quote": "explore the risk factors for postoperative anal fistula and perianal abscess recurrence" }, { "field": "result", "quote": "The postoperative fistula rate was 4.9%, and the abscess recurrence rate was 8.1%." }, { "field": "result", "quote": "The total success rate was 87.0%." }, { "field": "followUp", "quote": "average follow-up time of 37.9 ± 16.8 months" } ] }, { "id": "pmid:41578630", "pmid": "41578630", "doi": "10.12659/MSM.949712", "nctId": null, "pmcid": "PMC12849397", "title": "Predictors of Recurrence in Pediatric Perianal Abscess and Fistula-In-Ano: Insights From a 5-Year Surgical Cohort Study", "firstAuthor": "Borkowski", "multipleAuthors": true, "journal": "Med Sci Monit", "year": 2026, "design": "retrospective", "n": 108, "nField": "reported", "population": "children aged 0 to 17 who had surgery for a perianal abscess or anal fistula", "intervention": "having a fistula present at the time of the first surgery", "comparator": "not having a fistula present at the time of the first surgery", "primaryOutcome": "return of the fistula or abscess after treatment", "result": "Fistula recurrence was much more common in children who already had a fistula at the first operation (31.6%) than in those who did not (10.1%); antibiotics, abscess size, and how long symptoms lasted did not predict recurrence.", "resultDirection": "mixed", "quality": "low", "qualityWhy": "It is a single-center look-back study without randomization, so it can show patterns but not prove what prevents fistulas.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective design, single tertiary center, and ultrasound often gave no definitive answer for fistula detection (67 of 99 cases).", "followUp": "", "plainFinding": "Early fistula predicts fistula coming back.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41578630/", "sourceText": "BACKGROUND Perianal abscess (PA) and fistula-in-ano (FIA) are common in children, particularly infants. Despite their frequency, their pathophysiology, diagnostic accuracy, and optimal treatment remain debated. This study aimed to evaluate recurrence rates after surgical treatment of PA and FIA and identify clinical factors associated with fistula formation, including ultrasound findings, antibiotic therapy, abscess size, and symptom duration in otherwise healthy pediatric patients. MATERIAL AND METHODS We retrospectively reviewed 108 pediatric patients (0-17 years) treated surgically for PA and/or FIA between January 2019 and February 2024 at a tertiary care center. Inclusion criteria were PA diagnosis and incision and drainage as primary management. Data included intraoperative findings, recurrence, antibiotic use, ultrasound results, symptom duration, and abscess size (infants only). RESULTS Intraoperative FIA was identified in 19/108 patients (17.8%). Overall recurrence occurred in 29 patients (26.9%). Recurrence of PA was more frequent in those with initial FIA (36.8%) than without (24.7%) but was not significant (P>0.05). However, FIA recurrence was significantly higher in patients with initial FIA (31.6% vs 10.1%, P=0.024). Among 99 patients undergoing ultrasound, diagnostic accuracy for PA was 100%. Regarding FIA, there were 3 false negatives and 5 false positives; in 67 cases, no definitive conclusion was provided. Antibiotic therapy, abscess size, and symptom duration showed no significant association with recurrence or FIA development. CONCLUSIONS Initial intraoperative detection of FIA significantly predicts future recurrence. Antibiotic use, symptom duration, and abscess size were not predictive. Findings highlight the need for improved diagnostic tools and standardized management protocols in pediatric PA and FIA.", "provenance": [ { "field": "n", "quote": "We retrospectively reviewed 108 pediatric patients (0-17 years) treated surgically for PA and/or FIA between January 2019 and February 2024" }, { "field": "population", "quote": "108 pediatric patients (0-17 years) treated surgically for PA and/or FIA between January 2019 and February 2024 at a tertiary care center" }, { "field": "intervention", "quote": "Intraoperative FIA was identified in 19/108 patients (17.8%)" }, { "field": "comparator", "quote": "Recurrence of PA was more frequent in those with initial FIA (36.8%) than without (24.7%)" }, { "field": "primaryOutcome", "quote": "evaluate recurrence rates after surgical treatment of PA and FIA and identify clinical factors associated with fistula formation" }, { "field": "result", "quote": "FIA recurrence was significantly higher in patients with initial FIA (31.6% vs 10.1%, P=0.024)" }, { "field": "result", "quote": "Antibiotic therapy, abscess size, and symptom duration showed no significant association with recurrence or FIA development." } ] }, { "id": "pmid:41420370", "pmid": "41420370", "doi": "10.1111/ans.70442", "nctId": null, "pmcid": null, "title": "Beyond the Knife: A Contemporary Review of Subcutaneous Abscesses", "firstAuthor": "Mersal", "multipleAuthors": true, "journal": "ANZ J Surg", "year": 2026, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with perianal abscesses", "intervention": "antibiotics given after incision and drainage", "comparator": "incision and drainage without antibiotics", "primaryOutcome": "prevention of fistula-in-ano (anal fistula) formation", "result": "trials disagree, but pooled data suggest a modest benefit from antibiotics in reducing fistula formation", "resultDirection": "mixed", "quality": "low", "qualityWhy": "this is a review summarizing conflicting trials rather than new controlled data, so the evidence behind this specific claim is weak and inconsistent", "directness": "direct", "relevanceNote": "", "limitations": "abstract itself states the trials conflict and that clinical judgment still matters", "followUp": "", "plainFinding": "Antibiotics may modestly lower fistula risk.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41420370/", "sourceText": "Subcutaneous abscesses are among the most common soft-tissue infections encountered in acute surgical and emergency practice. While incision and drainage (I&D) remains the cornerstone of treatment, the best post-I&D strategy remains debated. Key questions include whether adjunct antibiotics improve cure rates or prevent recurrence, whether packing the cavity provides any advantage, and whether modern alternatives such as primary closure, drains, or irrigation offer superior outcomes. These issues are particularly relevant to perianal abscesses, where the risk of developing a fistula-in-ano is substantial, and to general cutaneous abscesses, where pain, delayed healing, and recurrence are frequent concerns. Recent randomized trials and contemporary guidelines have begun to clarify these controversies, helping clinicians move beyond traditional dogma toward evidence-based, patient-centered care. Landmark evidence now shows that, for uncomplicated cutaneous abscesses, adding a short course of MRSA-active antibiotics to I&D improves short-term cure and reduces new lesions. For perianal abscesses, the goal shifts to preventing fistula-in-ano: here the trials conflict, pooled estimates hint at a modest benefit from antibiotics, and clinical judgment still matters. Perhaps the clearest evidence-based shift is against routine packing, as it offers no outcome advantage and clearly increases pain. Large randomized data support abandoning it in favor of simple dressings or selective drains. Modern, patient-centered management now emphasizes thorough drainage, selective antibiotics, and avoidance of routine packing; use simple dressings or short-term drains when needed, and arrange reliable follow-up. That combination reduces pain and resource use without sacrificing safety.", "provenance": [ { "field": "population", "quote": "perianal abscesses, where the risk of developing a fistula-in-ano is substantial" }, { "field": "intervention", "quote": "adding a short course of MRSA-active antibiotics to I&D" }, { "field": "comparator", "quote": "whether adjunct antibiotics improve cure rates or prevent recurrence" }, { "field": "primaryOutcome", "quote": "the goal shifts to preventing fistula-in-ano" }, { "field": "result", "quote": "here the trials conflict, pooled estimates hint at a modest benefit from antibiotics, and clinical judgment still matters" } ] }, { "id": "pmid:41047078", "pmid": "41047078", "doi": "10.1016/j.clinre.2025.102706", "nctId": null, "pmcid": null, "title": "Does antibiotic therapy for anal abscess reduce the risk of fistula surgery? A retrospective study", "firstAuthor": "Alam", "multipleAuthors": true, "journal": "Clin Res Hepatol Gastroenterol", "year": 2025, "design": "retrospective", "n": 109, "nField": "reported", "population": "adults with a first-time perianal (anal) abscess treated with incision", "intervention": "antibiotic therapy given after incision of the abscess", "comparator": "incision alone without antibiotics", "primaryOutcome": "rate of patients needing fistula surgery and/or having the abscess come back", "result": "absence of antibiotic therapy after incision was linked to higher recurrence risk (OR 0.44)", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a small retrospective study using only univariate analysis, so the antibiotic link to fewer fistulas is not strongly proven.", "directness": "direct", "relevanceNote": "", "limitations": "Retrospective design, no multivariate analysis due to insufficient data, and authors call for randomized trials to confirm findings.", "followUp": "approximately 30 months", "plainFinding": "Antibiotics may lower fistula recurrence risk.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41047078/", "sourceText": "BACKGROUND: Management of first-time perianal abscesses remains controversial. While the French school of proctology systematically investigates fistulas, other approaches advocate simple incision, given that over 60 % of patients do not develop recurrence. The role of post-incision antibiotic therapy is also debated. This study aimed at evaluating our department's approach to managing first perianal abscesses and identifying predictive factors for recurrence. METHODS: We retrospectively included all patients presenting in 2019 with a first perianal abscess treated by incision under local anesthesia, with or without antibiotic therapy post-incision. Patients with evident fistulas underwent surgery. Recurrence was defined as a new abscess or purulent opening. The primary outcome was the rate of patients requiring fistula surgery and/or experiencing abscess recurrence; secondary outcomes included identification of recurrence predictors. RESULTS: Among the 336 patients who consulted for an abscess, 109 were included. Among 109 patients (mean age 43 ± 13 years; 74 % male), 55 had incision alone, and 54 underwent fistula surgery. The mean follow-up for patients with incision alone was approximately 30 months, during which 18 % (10 patients) experienced abscess recurrence. Univariate logistic regression analysis revealed smoking and absence of antibiotic therapy post-incision as predictive of recurrence with (OR 0.44) were predictive of recurrence. Gender, age, BMI, diabetes, Crohn's disease, HIV infection, prior NSAID use, and abscess location were not predictive. Multivariate analysis was not conducted due to insufficient data. CONCLUSION: This study demonstrates that 41 % of patients who underwent incision for a first perianal abscess did not experience recurrence during the follow-up period. Additionally, the administration of antibiotic therapy post-incision was associated with a reduced likelihood of recurrence. However, randomized trials are warranted to validate these findings and specify the optimal antibiotic regimen.", "provenance": [ { "field": "n", "quote": "Among 109 patients (mean age 43 ± 13 years; 74 % male)" }, { "field": "population", "quote": "all patients presenting in 2019 with a first perianal abscess treated by incision under local anesthesia" }, { "field": "intervention", "quote": "with or without antibiotic therapy post-incision" }, { "field": "comparator", "quote": "55 had incision alone" }, { "field": "primaryOutcome", "quote": "The primary outcome was the rate of patients requiring fistula surgery and/or experiencing abscess recurrence" }, { "field": "result", "quote": "Univariate logistic regression analysis revealed smoking and absence of antibiotic therapy post-incision as predictive of recurrence with (OR 0.44)" }, { "field": "followUp", "quote": "The mean follow-up for patients with incision alone was approximately 30 months" } ] }, { "id": "pmid:41035902", "pmid": "41035902", "doi": "10.1093/gastro/goaf091", "nctId": null, "pmcid": "PMC12479394", "title": "A randomized controlled trial of trans-intersphincteric double seton (TRISDS) for the treatment of perianal abscess", "firstAuthor": "Zhang", "multipleAuthors": true, "journal": "Gastroenterol Rep (Oxf)", "year": 2025, "design": "rct", "n": 106, "nField": "reported", "population": "adults with perianal abscesses below the levator ani muscle with an internal opening", "intervention": "trans-intersphincteric double seton technique (TRISDS) using two loose setons to drain abscess while preserving sphincter", "comparator": "conventional incision and drainage (I&D)", "primaryOutcome": "cure rate: complete wound healing without fistula or recurrence within 12 months", "result": "TRISDS had a significantly higher cure rate (78.2%) than I&D (41.2%), with no difference in anal function at 2 months", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "it was a randomized trial with a clear primary outcome, but it was not blinded and came from a single center.", "directness": "direct", "relevanceNote": "", "limitations": "non-blinded, single study, and authors recommend further multicenter studies to confirm findings", "followUp": "12 months", "plainFinding": "Fewer fistulas after this draining technique.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41035902/", "sourceText": "BACKGROUND: Incision and drainage (I&D) for perianal abscesses is associated with high rates of fistula formation. Our study aimed to evaluate the effectiveness of a novel technique, trans-intersphincteric double seton (TRISDS), designed to preserve anal sphincter integrity and improve clinical outcomes compared to I&D. METHODS: This prospective, randomized, non-blinded controlled study included adult patients with perianal abscesses located below the levator ani muscle with an internal opening. Patients were randomly assigned to either the TRISDS group (n = 55) or the I&D group (n = 51). The TRISDS technique involved two incisions: intersphincteric and drainage incisions with the placement of two loose setons. One seton was positioned to preserve the internal anal sphincter and facilitate drainage through the intersphincteric space, while the other seton aimed to protect the external anal sphincter to ensure comprehensive drainage. The I&D group underwent conventional I&D without damaging the anal sphincter complex. The primary outcome was the cure rate of perianal abscesses, which was defined as complete epithelialization of wounds without fistula or exudate and no recurrence within 12 months after surgery. RESULTS: The TRISDS group achieved a significantly higher cure rate of 78.2% (43/55) compared to 41.2% (21/51) in the I&D group (P < 0.05). There were no significant differences in anal function at 2 months postoperatively between the groups (median Wexner score, IQR: 1.0 [0.0-1.0] vs 1.0 [0.0-1.0], P > 0.05). CONCLUSIONS: The study highlighted the effectiveness of TRISDS in improving cure rate without compromising anal function. The TRISDS technique represents a promising strategy for the treatment of perianal abscesses. Further multicenter studies are recommended to validate these findings and expand the application of TRISDS in diverse patient populations.", "provenance": [ { "field": "n", "quote": "TRISDS group (n = 55) or the I&D group (n = 51)" }, { "field": "population", "quote": "adult patients with perianal abscesses located below the levator ani muscle with an internal opening" }, { "field": "intervention", "quote": "trans-intersphincteric double seton (TRISDS), designed to preserve anal sphincter integrity" }, { "field": "comparator", "quote": "conventional I&D without damaging the anal sphincter complex" }, { "field": "primaryOutcome", "quote": "The primary outcome was the cure rate of perianal abscesses, which was defined as complete epithelialization of wounds without fistula or exudate and no recurrence within 12 months after surgery." }, { "field": "result", "quote": "The TRISDS group achieved a significantly higher cure rate of 78.2% (43/55) compared to 41.2% (21/51) in the I&D group (P < 0.05)." } ] }, { "id": "pmid:41019154", "pmid": "41019154", "doi": "10.2147/JMDH.S537028", "nctId": null, "pmcid": "PMC12474735", "title": "Multifactorial Analysis of Postoperative Recurrence of Anal Fistula: A Retrospective Study", "firstAuthor": "Fang", "multipleAuthors": true, "journal": "J Multidiscip Healthc", "year": 2025, "design": "case-control", "n": 435, "nField": "reported", "population": "patients who had surgery for a perianal abscess", "intervention": "standardized dressing changes after discharge, preoperative ultrasound or MRI scan, and postoperative anal function assessment", "comparator": "patients with a history of abscesses, enteritis, intraoperative pus cavity residue, and other risk factors", "primaryOutcome": "formation of an anal fistula after perianal abscess surgery", "result": "several factors were independently linked to fistula formation, including abscess history, enteritis, residual pus cavity, surgeon specialty, Parks classification and Wexner score, while standardized dressing changes and preoperative imaging were linked to lower risk", "resultDirection": "mixed", "quality": "low", "qualityWhy": "It is a retrospective observational study with only 27 fistula cases, so it can show links but not prove these factors actually prevent fistulas.", "directness": "direct", "relevanceNote": "", "limitations": "Retrospective design, small number of fistula events, and reliance on multivariate analysis rather than a controlled trial.", "followUp": "25 months (range 18-40 months)", "plainFinding": "Several risk and protective factors identified.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41019154/", "sourceText": "BACKGROUND: The aim of this study is to investigate the main factors that influence the recurrence of anal fistulas in patients with perianal abscesses following incision and drainage treatment. METHODS: A retrospective case-control study was performed according to the STROBE guidelines for patients with perianal abscesses who underwent surgical treatment at Guangdong Provincial Hospital of Chinese Medicine in Zhuhai and at the Affiliated Hospital of Xuzhou Medical University in Lasso between June 2021 and June 2023. Lasso and multivariate logistic regression analyses were performed to further determine the recurrence of perianal abscesses. RESULTS: A total of 435 patients were included in the study, with a median follow-up period of 25 months (range 18-40 months) after receiving treatment for perianal abscesses. Of these patients, 27 were in the anal fistula group and 408 were in the cured group. The results of the multivariate logistic regression analysis showed that a history of abscesses, enteritis, intraoperative pus cavity residue, standardized dressing changes after discharge, the surgeon's specialty, preoperative ultrasound or MRI examination, Parks classification and Wexner score were independently influential factors in the formation of anal fistulas after perianal abscess surgery (P < 0.05). CONCLUSION: A history of abscesses and enteritis, Parks classification, and intraoperative pus cavity residue are high-risk factors for anal fistula recurrence. Standardized dressing changes after discharge, a preoperative ultrasound or MRI scan, and a postoperative assessment of anal function (Wexner score) are important for protecting anal sphincter function and improving the prognosis of perianal abscesses.", "provenance": [ { "field": "n", "quote": "A total of 435 patients were included in the study" }, { "field": "population", "quote": "patients with perianal abscesses who underwent surgical treatment" }, { "field": "intervention", "quote": "Standardized dressing changes after discharge, a preoperative ultrasound or MRI scan, and a postoperative assessment of anal function (Wexner score) are important for protecting anal sphincter function and improving the prognosis of perianal abscesses." }, { "field": "comparator", "quote": "A history of abscesses and enteritis, Parks classification, and intraoperative pus cavity residue are high-risk factors for anal fistula recurrence." }, { "field": "primaryOutcome", "quote": "the recurrence of anal fistulas in patients with perianal abscesses following incision and drainage treatment" }, { "field": "result", "quote": "a history of abscesses, enteritis, intraoperative pus cavity residue, standardized dressing changes after discharge, the surgeon's specialty, preoperative ultrasound or MRI examination, Parks classification and Wexner score were independently influential factors in the formation of anal fistulas after perianal abscess surgery (P < 0.05)." }, { "field": "followUp", "quote": "median follow-up period of 25 months (range 18-40 months)" } ] }, { "id": "pmid:40983150", "pmid": "40983150", "doi": "10.1016/j.jpedsurg.2025.162691", "nctId": null, "pmcid": null, "title": "Management of Perianal Abscesses in Infants: A Systematic Review From the APSA Outcomes and Evidence-Based Practice Committee", "firstAuthor": "Acker", "multipleAuthors": true, "journal": "J Pediatr Surg", "year": 2025, "design": "systematic-review", "n": null, "nField": "not-reported", "population": "infants with perianal abscess or anal fistula", "intervention": "surgical drainage or fistula surgery", "comparator": "non-operative care such as hygiene, warm baths, and antibiotics", "primaryOutcome": "rate of developing an anal fistula after treatment", "result": "about 21% developed a fistula after non-surgical care versus 20% after surgical drainage, with no clear difference between approaches", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "based on a mix of lower-quality studies (level 3-4 evidence) without randomized trials, so the comparison between treatments is uncertain.", "directness": "direct", "relevanceNote": "", "limitations": "Level 3-4 studies only; no randomized controlled trials; wide variation in time to resolution not explained", "followUp": "", "plainFinding": "No difference in fistula prevention.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40983150/", "sourceText": "BACKGROUND: Management of infant perianal disease, including perianal abscess and fistula-in- ano (FIA), remains controversial. There is lack of consensus regarding the risks and benefits of operative and non-operative approaches. METHODS: The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee created a priori consensus-based questions regarding the various approaches to management of perianal abscess and FIA in infants. A comprehensive search strategy was created, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to identify and review relevant articles and answer the established questions. RESULTS: Over 2460 titles and abstracts were screened to identify 31 manuscripts describing the expected course of perianal disease when managed with nonoperative management (NOM) strategies (such as hygiene, sitz baths, and systemic antibiotics), operative intervention for abscess only (incision and drainage (I&D)) or direct surgical management of the FIA (e.g. upfront fistulotomy). Initial failure of NOM is approximately 37.5 %. Recurrence rate after initial success with NOM or I&D is approximately 21 % and 24 %, respectively. The rate of FIA development is approximately 21 % after NOM and 20 % after I&D. Recurrence after operative management of FIA, regardless of approach, is 7 %. Time to complete resolution varies widely and does not appear to differ based on treatment strategy. CONCLUSIONS: Both operative and non-operative approaches can be safely used in the management of perianal abscess and FIA but recurrence is common regardless of approach. Risks and benefits of each approach should be considered on a case-by-case basis. TYPE OF STUDY: Systematic Review of level 3-4 studies. LEVEL OF EVIDENCE: Level 4.", "provenance": [ { "field": "population", "quote": "Management of infant perianal disease, including perianal abscess and fistula-in- ano (FIA)" }, { "field": "intervention", "quote": "operative intervention for abscess only (incision and drainage (I&D)) or direct surgical management of the FIA (e.g. upfront fistulotomy)" }, { "field": "comparator", "quote": "nonoperative management (NOM) strategies (such as hygiene, sitz baths, and systemic antibiotics)" }, { "field": "primaryOutcome", "quote": "The rate of FIA development is approximately 21 % after NOM and 20 % after I&D." }, { "field": "result", "quote": "The rate of FIA development is approximately 21 % after NOM and 20 % after I&D." }, { "field": "result", "quote": "Time to complete resolution varies widely and does not appear to differ based on treatment strategy." } ] }, { "id": "pmid:40898530", "pmid": "40898530", "doi": "10.1097/MD.0000000000044175", "nctId": null, "pmcid": "PMC12401249", "title": "Gut microbiota and perianal abscess and anal fistula: A bidirectional Mendelian randomization study", "firstAuthor": "He", "multipleAuthors": true, "journal": "Medicine (Baltimore)", "year": 2025, "design": "registry", "n": null, "nField": "not-reported", "population": "people studied using genetic data on gut bacteria and perianal abscess/anal fistula", "intervention": "specific gut bacteria types (genetically predicted levels)", "comparator": "other gut bacteria types / genetic variation without these bacteria", "primaryOutcome": "risk of developing perianal abscess or anal fistula", "result": "Several gut bacteria types were linked to higher or lower risk of perianal abscess and anal fistula; some bacteria increased risk, others appeared protective, based on genetic analysis", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This is a genetic correlation study, not a trial testing an actual prevention method, so it cannot show that changing gut bacteria would actually prevent fistulas.", "directness": "indirect", "relevanceNote": "", "limitations": "Abstract does not report study limitations beyond stating sensitivity analyses were robust; no human intervention was tested, only genetic association data was used.", "followUp": "", "plainFinding": "Certain gut bacteria linked to fistula risk.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40898530/", "sourceText": "Perianal abscess and anal fistula are debilitating surgical conditions characterized by severe pain, persistent pus discharge, and prolonged recovery periods with high recurrence rates, collectively imposing profound burdens on patients' quality of life, social functioning, and work productivity. Research has indicated potential distinction regarding the composition of gut microbiota in patients suffering from perianal abscess and anal fistula. The causal effect is yet unclear. The MiBioGen consortium was utilized to acquire data pertaining to gut microbiota, while the outcome data was provided by another project called the MRC Integrative Epidemiology Unit Open Genome-wide Association Studies (IEU Open GWAS) project. We performed bidirectional two-sample Mendelian randomization (MR) using inverse variance weighted (IVW) as the primary method, selected for its robustness to balanced pleiotropy when valid instrumental variables are used. Additionally, sensitivity analyses were conducted to examine the robustness of the results. Four gut microbiota taxa showed causal associations with perianal abscess risk: Eubacterium brachy group (OR = 1.41, P = .004), Ruminococcaceae UCG003 (OR = 0.61, P = .007), Erysipelatoclostridium (OR = 0.68, P = .009), and Butyrivibrio (OR = 0.81, P = .016). For anal fistula, 8 taxa were significant: Catenibacterium (OR = 1.22, P = .042) and Eubacterium ruminantium group (OR = 1.17, P = .013) increased risk, while Haemophilus (OR = 0.79, P = .005), Alloprevotella (OR = 0.78, P = .001), Ruminiclostridium5 (OR = 0.79, P = .019), Erysipelotrichaceae UCG003 (OR = 0.82, P = .034), Butyrivibrio (OR = 0.88, P = .006), and Escherichia-Shigella (OR = 0.82, P = .039) conferred protection. Furthermore, the findings from the sensitivity analyses demonstrate robust stability in these conclusions. Reverse MR analyses did not suggest reverse causality. This is the first MR investigation into the causal relationships between the onset of perianal infections and particular taxa of the gut microbiota. It enhances our comprehension of the correlation.", "provenance": [ { "field": "population", "quote": "Perianal abscess and anal fistula are debilitating surgical conditions" }, { "field": "intervention", "quote": "Four gut microbiota taxa showed causal associations with perianal abscess risk" }, { "field": "comparator", "quote": "Reverse MR analyses did not suggest reverse causality." }, { "field": "primaryOutcome", "quote": "causal associations with perianal abscess risk" }, { "field": "result", "quote": "Catenibacterium (OR = 1.22, P = .042) and Eubacterium ruminantium group (OR = 1.17, P = .013) increased risk, while Haemophilus (OR = 0.79, P = .005), Alloprevotella (OR = 0.78, P = .001), Ruminiclostridium5 (OR = 0.79, P = .019), Erysipelotrichaceae UCG003 (OR = 0.82, P = .034), Butyrivibrio (OR = 0.88, P = .006), and Escherichia-Shigella (OR = 0.82, P = .039) conferred protection." } ] }, { "id": "pmid:40585484", "pmid": "40585484", "doi": "10.3389/fsurg.2025.1572049", "nctId": null, "pmcid": "PMC12202503", "title": "Treatment of perianal abscess and anal fistula in infants: a systematic review", "firstAuthor": "Chen", "multipleAuthors": true, "journal": "Front Surg", "year": 2025, "design": "systematic-review", "n": 1770, "nField": "reported", "population": "perianal abscess (PA) and fistula-in-ano (FIA) in infants", "intervention": "conservative treatment (non-surgical)", "comparator": "surgical treatment", "primaryOutcome": "cure rate and recurrence (including new fistula formation)", "result": "similar cure and recurrence rates between conservative and surgical treatment, with fistula developing in about a quarter of cases either way", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "based only on pooled retrospective studies without randomization, so differences between treatments are uncertain.", "directness": "direct", "relevanceNote": "", "limitations": "all included studies were retrospective; no randomized trials.", "followUp": "", "plainFinding": "No difference between surgery and waiting.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40585484/", "sourceText": "INTRODUCTION: The optimal treatment approach for perianal abscess (PA) and fistula-in-ano (FIA) in infants remains a subject of debate. MATERIAL AND METHODS: A thorough literature search was conducted across multiple databases, including Embase, PubMed, Web of Science, Cochrane Library, ClinicalTrials.gov, and Google Scholar. RESULTS: A total of eighteen retrospective studies, encompassing 1,770 patients, were analyzed. Of the 702 cases (38.7%) that underwent conservative treatment, 528 cases (75.2%) achieved a cure, while 174 cases (24.8%) were unsuccessful, with 93 experiencing PA recurrence and 81 developing FIA. In contrast, among the 1,068 cases (61.3%) that received surgical interventions, 784 cases (73.4%) were cured, whereas 284 cases (26.6%) were not, with 151 experiencing PA recurrence and 133 developing FIA. CONCLUSION: The available studies indicate minimal differences in the cure and recurrence rates of PA and FIA between the conservative and surgical treatment groups. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/, PROSPERO (CRD42023472249).", "provenance": [ { "field": "n", "quote": "A total of eighteen retrospective studies, encompassing 1,770 patients, were analyzed." }, { "field": "population", "quote": "The optimal treatment approach for perianal abscess (PA) and fistula-in-ano (FIA) in infants remains a subject of debate." }, { "field": "intervention", "quote": "Of the 702 cases (38.7%) that underwent conservative treatment, 528 cases (75.2%) achieved a cure" }, { "field": "comparator", "quote": "among the 1,068 cases (61.3%) that received surgical interventions, 784 cases (73.4%) were cured" }, { "field": "primaryOutcome", "quote": "174 cases (24.8%) were unsuccessful, with 93 experiencing PA recurrence and 81 developing FIA" }, { "field": "result", "quote": "The available studies indicate minimal differences in the cure and recurrence rates of PA and FIA between the conservative and surgical treatment groups." } ] }, { "id": "pmid:39693822", "pmid": "39693822", "doi": "10.1016/j.jpedsurg.2024.162101", "nctId": null, "pmcid": null, "title": "Non-operative Versus Operative Management of Perianal Abscess in Infants: A 10-year Retrospective Study at Two Centres in the United Kingdom", "firstAuthor": "Neville", "multipleAuthors": true, "journal": "J Pediatr Surg", "year": 2025, "design": "retrospective", "n": 116, "nField": "reported", "population": "infants aged ≤12 months presenting with PA", "intervention": "surgical incision and drainage of perianal abscess", "comparator": "non-operative management (antibiotics and/or aspiration under local anaesthetic)", "primaryOutcome": "recurrence of perianal abscess and development of fistula-in-ano", "result": "Abscess recurrence was higher with non-operative management (53%) than surgery (23%), and surgery lowered recurrence risk, but fistula rates afterward were similar between groups", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This is a retrospective, non-randomized study from two centres with short follow-up, so differences could be due to other factors rather than treatment choice.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective design, management based on surgeon preference, short median follow-up of 3 months, and no randomisation to treatment groups.", "followUp": "3 (IQR 2-6) months", "plainFinding": "Surgery cut recurrence, not fistula rates.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/39693822/", "sourceText": "BACKGROUND: Perianal abscess (PA), with or without fistula-in-ano (FIA) is common in infants. Treatment options include incision and drainage under general anaesthesia or non-operative treatments, such as antibiotics and/or aspiration under local anaesthetic, which avoid the risks of surgery. Current management is based on surgeon preference due to a poor underlying evidence base. In this study we aimed to compare outcomes for non-operative and operative management of infant PA. METHODS: 10-year retrospective review (2012-2022) of infants aged ≤12 months presenting with PA to two paediatric surgery centres in the United Kingdom. Clinical features, management and outcome data were extracted from electronic records. RESULTS: 116 infants were identified; 113/116 (97 %) were male. Median age at presentation was 2 (IQR 1-6) months. Initial management was non-operative in 73/116 (63 %) and operative in 43/80 (37 %). Median follow-up was 3 (IQR 2-6) months. Recurrence occurred in 49/116 (42 %) at a median time of 1 (IQR 0-3) month and was significantly higher in the non-operative compared to the operative group (39/73 [53 %] versus 10/43 [23 %], p = 0.001). Operative management was independently associated with a reduced risk of PA recurrence (OR 0.25 [95 % confidence interval 0.09-0.68], p = 0.007). Further surgery was performed in 26/73 (36 %) in the non-operative group and 7/43 (16 %) in the operative group (p = 0.026). Subsequent FIA rates were not significantly different (23/73 [32 %] versus 8/43 [19 %], p = 0.129). CONCLUSIONS: In this study, PA recurrence and the requirement for further operative intervention were significantly higher when a PA was initially managed non-operatively, although subsequent FIA rates were similar.", "provenance": [ { "field": "n", "quote": "116 infants were identified" }, { "field": "population", "quote": "infants aged ≤12 months presenting with PA" }, { "field": "intervention", "quote": "Initial management was non-operative in 73/116 (63 %) and operative in 43/80 (37 %)." }, { "field": "comparator", "quote": "non-operative treatments, such as antibiotics and/or aspiration under local anaesthetic" }, { "field": "primaryOutcome", "quote": "Recurrence occurred in 49/116 (42 %) at a median time of 1 (IQR 0-3) month and was significantly higher in the non-operative compared to the operative group (39/73 [53 %] versus 10/43 [23 %], p = 0.001)." }, { "field": "result", "quote": "Subsequent FIA rates were not significantly different (23/73 [32 %] versus 8/43 [19 %], p = 0.129)." }, { "field": "followUp", "quote": "Median follow-up was 3 (IQR 2-6) months." } ] }, { "id": "pmid:39649212", "pmid": "39649212", "doi": "10.4240/wjgs.v16.i11.3425", "nctId": null, "pmcid": "PMC11622080", "title": "Proposal for a new classification of anorectal abscesses based on clinical characteristics and postoperative recurrence", "firstAuthor": "Chen", "multipleAuthors": true, "journal": "World J Gastrointest Surg", "year": 2024, "design": "retrospective", "n": 525, "nField": "reported", "population": "adults with anorectal abscesses treated with incision and drainage only at a hospital", "intervention": "incision and drainage performed promptly (within 7 days of symptoms)", "comparator": "incision and drainage delayed 7 or more days after symptoms, or done under local anesthesia", "primaryOutcome": "abscess coming back or turning into a fistula after surgery, tracked for one year", "result": "Overall recurrence was 39%, much higher for abscesses classed as fistula-prone (81.0%) than non-fistula-prone (23.5%); delaying surgery 7+ days, chronic diarrhea, and local anesthesia raised recurrence risk, while prompt thorough drainage lowered it", "resultDirection": "mixed", "quality": "low", "qualityWhy": "It only looked back at hospital records from one center without comparing treatments head-to-head, so it can show links but not prove what truly prevents fistulas.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective single-center design, no randomization, relies on electronic records, so findings show association with recurrence rather than proven prevention of fistula formation.", "followUp": "One year post-follow-up", "plainFinding": "Early thorough drainage cuts recurrence risk.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/39649212/", "sourceText": "BACKGROUND: Current surgical procedures for anorectal abscesses, including incision and drainage alone or combined concurrent fistulotomy, remain controversial primarily due to the unpredictability of postoperative recurrence or the progression to anal fistula. AIM: To evaluate factors that predict postoperative recurrence of anorectal abscesses and propose a new classification to guide surgical procedures. METHODS: In this retrospective study, 525 patients with anorectal abscesses treated by incision and drainage alone, at a tertiary general hospital from August 2012 to July 2022, were included. A new classification for anorectal abscesses based on their propensity to develop into fistulas, considering 18 other potential risk factors, was established. These factors, from electronic medical records, were screened for significance using the χ² test and subsequently analyzed with multivariate logistic regression to evaluate their relationship with postoperative recurrence of anorectal abscesses. RESULTS: One year post-follow-up, the overall recurrence rate was 39%:81.0% and 23.5% for fistula-prone and non-fistula-prone abscesses, respectively. Univariate χ² analysis showed significant differences in recurrence rates based on anatomical classifications and pus culture results (P < 0.05). Fistula-prone abscess, ≥ 7 days between symptom onset and surgery, chronic diarrhea, preoperative antibiotic use, and local anesthesia were risk factors for recurrence, while diabetes mellitus was protective (P < 0.05). Moreover, fistula-prone abscess [odds ratio (OR) = 7.651, 95%CI: 4.049-14.458, P < 0.001], ≥ 7 days from symptom onset to surgery (OR = 2.137, 95%CI: 1.090-4.190, P = 0.027), chronic diarrhea (OR = 2.508, 95%CI: 1.216-5.173, P = 0.013), and local anesthesia (OR = 2.308, 95%CI: 1.313-4.059, P = 0.004) were independent risk factors for postoperative anorectal abscess recurrence using multivariate logistic regression. Body mass index ≥ 28 (OR = 2.935, 95%CI: 1.203-7.165, P = 0.018) was an independent risk factor for postoperative recurrence of non-fistula-prone abscess. CONCLUSION: The choice of surgical procedure for treating anorectal abscesses should follow this new classification. Prompt and thorough incision and drainage can significantly reduce postoperative recurrence.", "provenance": [ { "field": "n", "quote": "In this retrospective study, 525 patients with anorectal abscesses treated by incision and drainage alone, at a tertiary general hospital from August 2012 to July 2022, were included." }, { "field": "population", "quote": "525 patients with anorectal abscesses treated by incision and drainage alone, at a tertiary general hospital from August 2012 to July 2022, were included" }, { "field": "intervention", "quote": "Prompt and thorough incision and drainage can significantly reduce postoperative recurrence." }, { "field": "comparator", "quote": "≥ 7 days between symptom onset and surgery, chronic diarrhea, preoperative antibiotic use, and local anesthesia were risk factors for recurrence" }, { "field": "primaryOutcome", "quote": "To evaluate factors that predict postoperative recurrence of anorectal abscesses and propose a new classification to guide surgical procedures." }, { "field": "result", "quote": "the overall recurrence rate was 39%:81.0% and 23.5% for fistula-prone and non-fistula-prone abscesses, respectively." }, { "field": "followUp", "quote": "One year post-follow-up" } ] }, { "id": "pmid:39399133", "pmid": "39399133", "doi": "10.1055/s-0043-1777451", "nctId": null, "pmcid": "PMC11466523", "title": "Anorectal Abscess", "firstAuthor": "Kata", "multipleAuthors": true, "journal": "Clin Colon Rectal Surg", "year": 2024, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with an anorectal abscess", "intervention": "draining the abscess (with discussion of antibiotics and primary fistulotomy)", "comparator": "different drainage/management approaches, with or without antibiotics or fistulotomy", "primaryOutcome": "whether an anal fistula develops after treatment", "result": "Review states 30 to 50% develop a fistula after drainage; whether antibiotics prevent this is still being studied and early fistulotomy is controversial", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a narrative review discussing general practice and open questions, not a study measuring outcomes itself.", "directness": "indirect", "relevanceNote": "", "limitations": "No original data, sample size, or methods are given; it summarizes general knowledge and notes some questions are unresolved.", "followUp": "", "plainFinding": "No clear way to prevent fistula yet.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/39399133/", "sourceText": "Anorectal abscesses are a common colorectal emergency. The hallmark of treatment is obtaining source control while avoiding injury to the underlying sphincter complex. Understanding the anatomy of an anorectal abscess is critical to planning the appropriate drainage strategy and decreasing the risk of complex fistula formation. Use of antibiotics should be reserved for those with extensive cellulitis, signs of systemic infection, or patients who are immunocompromised. Whether antibiotics prevent future fistula formation is an area of active research. Primary fistulotomy at time of the index drainage is controversial; however, there may be situations where it is appropriate. It is important to counsel patients that after effective drainage of an anorectal abscess, they have a 30 to 50% chance of developing an anal fistula that will then require further treatment.", "provenance": [ { "field": "population", "quote": "Anorectal abscesses are a common colorectal emergency." }, { "field": "intervention", "quote": "The hallmark of treatment is obtaining source control while avoiding injury to the underlying sphincter complex." }, { "field": "comparator", "quote": "Primary fistulotomy at time of the index drainage is controversial; however, there may be situations where it is appropriate." }, { "field": "primaryOutcome", "quote": "they have a 30 to 50% chance of developing an anal fistula that will then require further treatment" }, { "field": "result", "quote": "Whether antibiotics prevent future fistula formation is an area of active research." }, { "field": "result", "quote": "they have a 30 to 50% chance of developing an anal fistula that will then require further treatment" } ] }, { "id": "pmid:38677815", "pmid": "38677815", "doi": "10.1016/j.suc.2023.11.002", "nctId": null, "pmcid": null, "title": "Anal Cryptoglandular Suppuration: Evidence-Based Management", "firstAuthor": "Akinmoladun", "multipleAuthors": true, "journal": "Surg Clin North Am", "year": 2024, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with anal gland infections and fistulas", "intervention": "different fistula treatments including sphincter-cutting surgery", "comparator": "sphincter-sparing fistula treatments", "primaryOutcome": "balance between incontinence risk and fistula coming back", "result": "the abstract does not report a specific outcome, only general discussion of treatment tradeoffs", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a narrative review discussing general treatment considerations without presenting original data or outcomes.", "directness": "indirect", "relevanceNote": "", "limitations": "this is a review article that does not report original study data, numbers, or specific results comparing treatments.", "followUp": "", "plainFinding": "No specific prevention finding reported.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38677815/", "sourceText": "Anal suppurative processes are commonly encountered in surgical practice. While the initial therapeutic intervention is philosophically straightforward (incision and drainage), drainage of the appropriate space and treatment of the subsequent fistula in ano require a thorough understanding of perianal anatomy and nuanced decision making. Balancing the risk of fecal incontinence with simple fistulotomy versus the higher risk of fistula recurrence with all sphincter-sparing fistula treatments can be a challenge for surgeons and patients alike.", "provenance": [ { "field": "population", "quote": "Anal suppurative processes are commonly encountered in surgical practice" }, { "field": "intervention", "quote": "the initial therapeutic intervention is philosophically straightforward (incision and drainage)" }, { "field": "comparator", "quote": "the higher risk of fistula recurrence with all sphincter-sparing fistula treatments" }, { "field": "primaryOutcome", "quote": "Balancing the risk of fecal incontinence with simple fistulotomy versus the higher risk of fistula recurrence with all sphincter-sparing fistula treatments can be a challenge for surgeons and patients alike." }, { "field": "result", "quote": "drainage of the appropriate space and treatment of the subsequent fistula in ano require a thorough understanding of perianal anatomy and nuanced decision making" } ] }, { "id": "pmid:38355562", "pmid": "38355562", "doi": "10.1186/s13063-024-07922-3", "nctId": null, "pmcid": "PMC10868096", "title": "Efficacy of amoxicillin/clavulanic acid after surgical drainage of perianal abscess in the prevention of the development of anal fistula (PERIQxA study): study protocol for a multicenter randomized, double-blind clinical trial", "firstAuthor": "Polaino Moreno", "multipleAuthors": true, "journal": "Trials", "year": 2024, "design": "registered-trial-no-results", "n": 286, "nField": "reported", "population": "adults who had surgery to drain a perianal abscess", "intervention": "amoxicillin/clavulanic acid antibiotic for 7 days", "comparator": "placebo", "primaryOutcome": "percentage of patients who develop an anal fistula after surgery", "result": "no results yet; this is a study protocol", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is only a trial protocol with no results reported yet, so no conclusion can be drawn.", "directness": "direct", "relevanceNote": "", "limitations": "The abstract reports no results; it only describes the planned study design.", "followUp": "6 months", "plainFinding": "No results yet; trial planned.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38355562/", "sourceText": "BACKGROUND: Anorectal fistula, which is a relatively common pathology, is the chronic manifestation of the acute perirectal process that forms an anal abscess. The development of a fistula after incision and drainage of an anal abscess is seen in approximately 26-37%. Its treatment is a relevant topic, and the role of the use of antibiotic therapy in its prevention remains controversial, after the publication of several studies with contradictory results and several methodological limitations. Our hypothesis is that the combination of amoxicillin and clavulanic acid will reduce the incidence of anal fistula. METHOD: The aim of this study is to evaluate the efficacy of antibiotherapy after surgical drainage of perianal abscess in the development of perianal fistula. The PERIQxA study is a multicenter, randomized, double-blind controlled trial. The study has been designed to include 286 adult patients who will be randomly (1:1) assigned to either the experimental (amoxicillin/clavulanic acid 875/125 mg TDS for 7 days) or the control arm (placebo). The primary outcome measure is the percentage of patients that develop perianal fistula after surgery and during follow-up (6 months). DISCUSSION: This clinical trial is designed to evaluate the efficacy and safety of amoxicillin/clavulanic in the prevention of perianal fistula. The results of this study are expected to contribute to stablish the potential role of antibiotherapy in the therapeutics for anal abscess. TRIAL REGISTRATION: EudraCT Number: 2021-003376-14. Registered on November 26, 2021.", "provenance": [ { "field": "n", "quote": "The study has been designed to include 286 adult patients" }, { "field": "population", "quote": "after surgical drainage of perianal abscess" }, { "field": "intervention", "quote": "experimental (amoxicillin/clavulanic acid 875/125 mg TDS for 7 days)" }, { "field": "comparator", "quote": "control arm (placebo)" }, { "field": "primaryOutcome", "quote": "The primary outcome measure is the percentage of patients that develop perianal fistula after surgery and during follow-up (6 months)." }, { "field": "result", "quote": "The results of this study are expected to contribute to stablish the potential role of antibiotherapy in the therapeutics for anal abscess." } ] }, { "id": "pmid:38259976", "pmid": "38259976", "doi": "10.3389/fsurg.2023.1329557", "nctId": null, "pmcid": "PMC10800495", "title": "Restricted cubic spline model analysis of the association between anal fistula and anorectal abscess incidence and body mass index", "firstAuthor": "Ye", "multipleAuthors": true, "journal": "Front Surg", "year": 2023, "design": "retrospective", "n": 1223, "nField": "reported", "population": "outpatients seen at a proctology clinic, some with anal fistula or anorectal abscess and some healthy controls", "intervention": "having a higher body mass index (overweight or obesity)", "comparator": "normal-weight individuals", "primaryOutcome": "developing anal fistula or anorectal abscess", "result": "overweight and obesity were linked to higher odds of anal fistula and anorectal abscess, with a J-shaped relationship between BMI and risk", "resultDirection": "harm", "quality": "low", "qualityWhy": "This is a retrospective observational study looking at associations, not a trial testing a way to prevent fistulas, so it cannot prove that losing weight prevents them.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective cross-sectional design, so it can show association but not prove cause, and it does not test any actual prevention method.", "followUp": "", "plainFinding": "Higher body weight linked to more fistulas.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38259976/", "sourceText": "OBJECTIVE: The epidemiological profile of anal fistula and anorectal abscess has not been well studied. Based on the results of a retrospective cross-sectional survey, we aimed to investigate the potential influential factors associated with anal fistula and anorectal abscess. METHODS: We conducted a retrospective analysis of outpatients who visited the proctology department at China-Japan Friendship Hospital between January 2017 and May 2022. A comprehensive questionnaire was designed to collect potential influential factors, and according to formal anorectal examination and the corresponding diagnostic criteria, all the participants were divided into patients with anal fistula or perianal abscess and healthy control group. Multiple logistic regression was used to identify factors in significant association with anal fistula and perianal abscess. Additionally, we combined restricted cubic spline regression to examine the dose-response relationship between factors and the risk of developing anal fistula or anorectal abscess. RESULTS: The present study included 1,223 participants, including 1,018 males and 206 females, with 275 anal fistulas, 184 anorectal abscesses, and 765 healthy controls. We found no statistically significant differences between patients and controls in basic information and preoperative assessment of life factors, except for body mass index. It was indicated that people with overweight or obesity were more prone to anal fistula (OR overweight = 1.35, 95% CI: 1.00-1.82, P = 0.047; OR obesity = 3.44, 95% CI: 2.26-5.26, P < 0.001) or anorectal abscess (OR overweight = 1.41, 95% CI: 1.00-1.99, P = 0.05; OR obesity: 2.24, 95% CI: 1.37-3.67, P = 0.001) than normal-weight individuals. The dose-response research indicated the J-shaped trend between the ascending BMI levels and the higher risk of suffering from anal fistula and anorectal abscess. CONCLUSIONS: Our findings indicate that overweight and obesity are risk factors for anal fistula and anorectal abscess, which plays a role in the prevention of anorectal diseases. This provides some theoretical basis for clinicians to provide health education to their patients.", "provenance": [ { "field": "n", "quote": "The present study included 1,223 participants, including 1,018 males and 206 females, with 275 anal fistulas, 184 anorectal abscesses, and 765 healthy controls." }, { "field": "population", "quote": "We conducted a retrospective analysis of outpatients who visited the proctology department at China-Japan Friendship Hospital between January 2017 and May 2022." }, { "field": "intervention", "quote": "people with overweight or obesity were more prone to anal fistula" }, { "field": "comparator", "quote": "than normal-weight individuals" }, { "field": "primaryOutcome", "quote": "the potential influential factors associated with anal fistula and anorectal abscess" }, { "field": "result", "quote": "It was indicated that people with overweight or obesity were more prone to anal fistula (OR overweight = 1.35, 95% CI: 1.00-1.82, P = 0.047; OR obesity = 3.44, 95% CI: 2.26-5.26, P < 0.001) or anorectal abscess (OR overweight = 1.41, 95% CI: 1.00-1.99, P = 0.05; OR obesity: 2.24, 95% CI: 1.37-3.67, P = 0.001) than normal-weight individuals." } ] }, { "id": "pmid:38131396", "pmid": "38131396", "doi": "10.1111/ans.18836", "nctId": null, "pmcid": null, "title": "Management of acute perianal abscess: is surgeon specialization associated with improved outcomes?", "firstAuthor": "Turner", "multipleAuthors": true, "journal": "ANZ J Surg", "year": 2024, "design": "retrospective", "n": 408, "nField": "reported", "population": "patients admitted with perianal abscess (excluding those with IBD, recent fistula treatment, or non-cryptoglandular sepsis)", "intervention": "abscess surgery performed by a colorectal specialist surgeon", "comparator": "abscess surgery performed by a non-colorectal general surgeon", "primaryOutcome": "abscess coming back (recurrence), and later fistula development", "result": "no difference in risk of recurrent abscess or later fistula between colorectal and non-colorectal surgeons", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "This is a retrospective cohort study with likely selection bias, as the authors themselves note.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective design with potential selection bias; colorectal surgeons more often identified fistulas at surgery, which could affect comparability between groups.", "followUp": "", "plainFinding": "Surgeon specialty didn't change fistula or recurrence rates.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38131396/", "sourceText": "BACKGROUND: Acute surgical units (ASU) are increasingly being adopted and in our system are staffed by colorectal and non-colorectal general surgeons. This study aims to evaluate whether surgeon specialization was associated with improved outcomes in perianal abscess. METHODS: Patients with perianal abscess admitted to the ASU between 2016 and 2020 were identified from a prospective database and their medical records reviewed. Patients with IBD, treatment for fistula-in-ano within the preceding year, or perianal sepsis of non-cryptoglandular origin were excluded. Patients admitted under an ASU colorectal (CR) consultant were compared with those under a non-CR general surgeon in a retrospective cohort study. Primary outcome was perianal abscess recurrence. For those without initial fistula, hazard of recurrent abscess or fistula was analysed. Multivariable Cox PH regression analysis was performed. RESULTS: Four-hundred and eight patients were included (150 CR, 258 non-CR). The CR group more frequently had a fistula identified at index operation (34.0% versus 10.9%, P < 0.0001). However, Cox multivariable analysis found no difference in hazard of recurrent abscess between groups (HR 1.12, 95% CI 0.65-1.95, P = 0.681)). Abscess recurred in 18.7% CR and 15.5% non-CR. Subsequent fistula developed in 14.7% in both groups. For patients without initial fistula, there was no difference between groups in hazard of recurrent abscess or fistula (HR 1.18, 95% CI 0.69-2.01, P = 0.539). CONCLUSION: Surgeon specialization was not associated with improved outcomes for ASU patients with perianal abscess, albeit with potential selection bias. CR surgeons were more proactive identifying fistulas; this raises the possibility that drainage alone may be adequate treatment.", "provenance": [ { "field": "population", "quote": "Patients with perianal abscess admitted to the ASU between 2016 and 2020 were identified from a prospective database" }, { "field": "n", "quote": "Four-hundred and eight patients were included (150 CR, 258 non-CR)." }, { "field": "intervention", "quote": "Patients admitted under an ASU colorectal (CR) consultant" }, { "field": "comparator", "quote": "compared with those under a non-CR general surgeon" }, { "field": "primaryOutcome", "quote": "Primary outcome was perianal abscess recurrence." }, { "field": "result", "quote": "Cox multivariable analysis found no difference in hazard of recurrent abscess between groups (HR 1.12, 95% CI 0.65-1.95, P = 0.681))." }, { "field": "result", "quote": "Subsequent fistula developed in 14.7% in both groups." }, { "field": "qualityWhy", "quote": "Surgeon specialization was not associated with improved outcomes for ASU patients with perianal abscess, albeit with potential selection bias." } ] }, { "id": "pmid:38093036", "pmid": "38093036", "doi": "10.1007/s00384-023-04576-6", "nctId": null, "pmcid": "PMC10719138", "title": "Fistula development after anal abscess drainage-a multicentre retrospective cohort study", "firstAuthor": "Skovgaards", "multipleAuthors": true, "journal": "Int J Colorectal Dis", "year": 2023, "design": "retrospective", "n": 475, "nField": "reported", "population": "adults who had surgery to drain an anal abscess", "intervention": "none - this study did not test a treatment, it looked for risk factors after standard abscess drainage surgery", "comparator": "patients without those risk factors", "primaryOutcome": "whether an anal fistula developed after abscess surgery", "result": "certain factors - low intersphincteric or ischioanal abscess location, Crohn's disease, repeat abscesses or repeat surgery, E. coli in the pus, and high CRP - were linked to higher odds of later fistula", "resultDirection": "unclear", "quality": "low", "qualityWhy": "it is a retrospective chart review from patient records, which can miss data and cannot prove these factors actually cause fistulas rather than just being associated with them", "directness": "indirect", "relevanceNote": "", "limitations": "retrospective design, reliance on coded records, and no testing of any preventive intervention", "followUp": "median follow-up time of 1108 days (IQR 946-1320 days)", "plainFinding": "Identified factors linked to fistula risk.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38093036/", "sourceText": "PURPOSE: Anal abscesses are common and, despite correct treatment with surgical drainage, carry the risk of developing fistulas. Studies identifying risk factors for the development of anal fistulas are sparse. This study aimed to identify the risk factors for anal fistulas after anal abscess surgery. METHODS: This was a multicentre, retrospective cohort study of patients undergoing acute surgery for anal abscesses in the Capital Region of Denmark between 2018 and 2019. The patients were identified using ICD-10 codes for anal abscesses. Predefined clinicopathological factors and postoperative courses were extracted from patient records. RESULTS: A total of 475 patients were included. At a median follow-up time of 1108 days (IQR 946-1320 days) following surgery, 164 (33.7%) patients were diagnosed with an anal fistula. Risk factors for developing fistulas were low intersphincteric (OR 2.77, 95CI 1.50-5.06) and ischioanal (OR 2.48, 95CI 1.36-4.47) abscesses, Crohn's disease (OR 5.96, 95CI 2.33-17.2), a history of recurrent anal abscesses (OR 4.14, 95CI 2.47-7.01) or repeat surgery (OR 5.96, 95CI 2.33-17.2), E. coli-positive pus cultures (OR 4.06, 1.56-11.4) or preoperative C-reactive protein (CRP) of more than 100 mg/L (OR 3.21, 95CI 1.57-6.71). CONCLUSION: Several significant clinical risk factors were associated with fistula development following anal abscess surgery. These findings are clinically relevant and could influence the selection of patients for specialised follow-up, facilitate expedited diagnosis, and potentially prevent unnecessarily long treatment courses.", "provenance": [ { "field": "n", "quote": "A total of 475 patients were included." }, { "field": "population", "quote": "patients undergoing acute surgery for anal abscesses in the Capital Region of Denmark between 2018 and 2019" }, { "field": "intervention", "quote": "This study aimed to identify the risk factors for anal fistulas after anal abscess surgery." }, { "field": "comparator", "quote": "Predefined clinicopathological factors and postoperative courses were extracted from patient records." }, { "field": "primaryOutcome", "quote": "164 (33.7%) patients were diagnosed with an anal fistula" }, { "field": "result", "quote": "Risk factors for developing fistulas were low intersphincteric (OR 2.77, 95CI 1.50-5.06) and ischioanal (OR 2.48, 95CI 1.36-4.47) abscesses, Crohn's disease (OR 5.96, 95CI 2.33-17.2), a history of recurrent anal abscesses (OR 4.14, 95CI 2.47-7.01) or repeat surgery (OR 5.96, 95CI 2.33-17.2), E. coli-positive pus cultures (OR 4.06, 1.56-11.4) or preoperative C-reactive protein (CRP) of more than 100 mg/L (OR 3.21, 95CI 1.57-6.71)." }, { "field": "followUp", "quote": "median follow-up time of 1108 days (IQR 946-1320 days)" } ] }, { "id": "pmid:37891236", "pmid": "37891236", "doi": "10.1038/s41598-023-45751-7", "nctId": null, "pmcid": "PMC10611711", "title": "Natural course of perianal abscess in infants: a real-world study", "firstAuthor": "Yin", "multipleAuthors": true, "journal": "Sci Rep", "year": 2023, "design": "retrospective", "n": 153, "nField": "reported", "population": "infants with perianal abscess treated without surgery", "intervention": "conservative (non-surgical) treatment of perianal abscess", "comparator": "", "primaryOutcome": "cure rate, fistula formation, abscess recurrence", "result": "most infants (90.8%) were cured without surgery; only about 7.2% needed surgery and 2% developed fistula-in-ano", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This is a retrospective single-center study without a comparison group, so it cannot prove what prevents fistula formation.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective design, single center, no control group, parents' refusal of surgery introduces selection bias.", "followUp": "5.3 years", "plainFinding": "Most abscesses healed without surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37891236/", "sourceText": "Natural course of perianal abscess (PA) in infancy remains obscure. This study aimed to investigate the natural course of infants with PA after conservative treatment. A retrospective cohort study was conducted in infants with PA who were treated conservatively (due to the parents' refusal of surgery), for more than 2 months between 2014 and 2020 at a single tertiary center. 153 patients (149 boys and 4 girls) were identified. The median follow-up was 5.3 years (range 3-8.2 years). Initially, 119 patients (77.8%) were completely cured by conservative treatment, and 34 (22.2%) failed. Among the 34 patients, 23 continued conservative treatment (20 cure, 3 fistula formation) and 11 underwent surgery. After conservative treatment, the rate of fistula formation, abscess recurrence, and new-onset abscess were 15.0%, 4.6%, and 6.5%, respectively. Overall, 139 patients (90.8%) were cured conservatively without surgery, and 11 (7.2%) underwent surgical management. In addition, 3 (2.0%) patients developed fistula-in-ano (under observation). PA in infants may be a time-limited and self-limited condition. Conservative management should be the first choice of treatment in most cases. Longer periods of conservative treatment may achieve better clinical outcomes in selected cases. There will be a percentage of patients (about 10%) that would require surgical treatment.", "provenance": [ { "field": "population", "quote": "A retrospective cohort study was conducted in infants with PA who were treated conservatively (due to the parents' refusal of surgery), for more than 2 months between 2014 and 2020 at a single tertiary center." }, { "field": "n", "quote": "153 patients (149 boys and 4 girls) were identified." }, { "field": "intervention", "quote": "infants with PA who were treated conservatively" }, { "field": "primaryOutcome", "quote": "the rate of fistula formation, abscess recurrence, and new-onset abscess were 15.0%, 4.6%, and 6.5%, respectively." }, { "field": "result", "quote": "Overall, 139 patients (90.8%) were cured conservatively without surgery, and 11 (7.2%) underwent surgical management." }, { "field": "followUp", "quote": "The median follow-up was 5.3 years (range 3-8.2 years)." } ] }, { "id": "pmid:37759161", "pmid": "37759161", "doi": "10.1186/s12876-023-02959-1", "nctId": null, "pmcid": "PMC10537581", "title": "Study on the factors influencing the prognosis after perianal abscess surgery", "firstAuthor": "Dong", "multipleAuthors": true, "journal": "BMC Gastroenterol", "year": 2023, "design": "retrospective", "n": 394, "nField": "reported", "population": "patients who had surgery for a perianal abscess", "intervention": "different surgical methods for treating the abscess (including precise clearance of the infected gland)", "comparator": "simple drainage surgery", "primaryOutcome": "abscess recurrence or formation of an anal fistula after surgery", "result": "larger abscess cavity size and type of surgical method used were independent risk factors for recurrence or fistula formation after surgery", "resultDirection": "mixed", "quality": "low", "qualityWhy": "this is a retrospective review of patient records without randomization, so it can show links but not prove that a surgical method actually causes fewer fistulas.", "directness": "direct", "relevanceNote": "", "limitations": "retrospective design, no randomization, and reliance on records for factors like preoperative imaging and abscess characteristics.", "followUp": "", "plainFinding": "Surgical method and abscess size affect fistula risk.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37759161/", "sourceText": "OBJECTIVE: To study the influence of clinical characteristics and diagnosis and treatment methods of perianal abscess on postoperative recurrence or formation of anal fistula to provide a basis for selecting appropriate surgical and inspection methods for clinical treatment of perianal abscess in the future. METHODS: The clinical data of 394 patients with perianal abscesses were collected, the influencing factors were investigated, and univariate analysis and multivariate logistic regression analysis were performed to further determine the risk factors affecting the prognosis of perianal abscess. RESULTS: The results showed that the rate of preoperative blood routine results in the uncured group was higher (51.16%) than in the cured group (35.61%); the rate of high abscess space in the uncured group (23.26%) was higher than in the cured group (9.11%); the proportion of patients in the uncured group who underwent magnetic resonance imaging (MRI) before surgery (27.90%) was lower than in the cured group (45.30%); the proportion of patients in the uncured group who underwent simple drainage (51.16%) was higher than in the cured group (28.49%). The two groups had significant differences in perineal MRI examination, surgical method, preoperative blood routine, and abscess space (p = 0.030, p = 0.002, p = 0.047 and p = 0.010, respectively). Based on the results of univariate analysis and multivariate logistic regression analysis, the extent of the abscess cavity (OR = 2.544, 95%CI = 1.087-5.954, p = 0.031) and the surgical method (OR = 2.180, 95%CI = 1.091-4.357, p = 0.027) were independent influencing factors for postoperative recurrence of perianal abscess or anal fistula. CONCLUSION: Preoperative assessment of the abscess range and precise intraoperative methods to resolve the infection of the abscess glands in the internal mouth can effectively improve the cure rate.", "provenance": [ { "field": "population", "quote": "The clinical data of 394 patients with perianal abscesses were collected" }, { "field": "n", "quote": "The clinical data of 394 patients with perianal abscesses were collected" }, { "field": "intervention", "quote": "surgical method" }, { "field": "comparator", "quote": "simple drainage" }, { "field": "primaryOutcome", "quote": "postoperative recurrence or formation of anal fistula" }, { "field": "result", "quote": "the extent of the abscess cavity (OR = 2.544, 95%CI = 1.087-5.954, p = 0.031) and the surgical method (OR = 2.180, 95%CI = 1.091-4.357, p = 0.027) were independent influencing factors for postoperative recurrence of perianal abscess or anal fistula" } ] }, { "id": "pmid:36894443", "pmid": "36894443", "doi": "10.1016/j.jpedsurg.2023.01.055", "nctId": null, "pmcid": null, "title": "The Optimal Primary Treatment for Pediatric Perianal Abscess and Anal Fistula: A Systemic Review and Meta-Analysis", "firstAuthor": "Lin", "multipleAuthors": true, "journal": "J Pediatr Surg", "year": 2023, "design": "meta-analysis", "n": 2507, "nField": "reported", "population": "children under 18 with perianal abscess or anal fistula", "intervention": "surgery (fistula surgery) as first treatment", "comparator": "conservative treatment or incision/drainage alone", "primaryOutcome": "recurrence of abscess or fistula after initial treatment", "result": "Surgery as the first treatment lowered recurrence compared with drainage alone, and conservative treatment had more recurrence than surgery, though not statistically significant", "resultDirection": "benefit", "quality": "low", "qualityWhy": "It pools mostly retrospective studies with no randomized trials, so the comparisons are prone to bias.", "directness": "indirect", "relevanceNote": "", "limitations": "No randomized controlled trials were identified; studies were mostly retrospective; subgroup analysis of different treatment approaches could not be performed due to lack of information.", "followUp": "", "plainFinding": "Early surgery reduced fistula recurrence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36894443/", "sourceText": "BACKGROUND: Perianal abscesses and anal fistulas are common. The principle of intention-to-treat has not been considered in previous systemic reviews. Thus, the comparison between primary and post-recurrence management was confused, and the recommendation of primary treatment is obscure. The current study aims to identify the optimal initial treatment for pediatric patients. METHODS: Using PRISMA guidelines, studies were identified from MEDLINE, EMBASE, PubMed, Cochrane Library, and Google Scholar without any language or study design restriction. The inclusion criteria include original articles or articles with original data, studies of management for a perianal abscess with or without anal fistula, and patient age of <18 years. Patients with local malignancy, Crohn's disease, or other underlying predisposing conditions were excluded. Studies without analyzing recurrence, case series of <5, and irrelevant articles were excluded in the screening stage. Of the 124 screened articles, 14 articles had no full texts or detailed information. Articles written in a language other than English or Mandarin were translated by Google Translation first and confirmed with native speakers. After the eligibility process, studies that compared identified primary managements were then included in the qualitative synthesis. RESULTS: Thirty-one studies involving 2507 pediatric patients met the inclusion criteria. The study design consisted of two prospective case series of 47 patients and retrospective cohort studies. No randomized control trials were identified. Meta-analyses for recurrence after initial management were performed with a random-effects model. Conservative treatment and drainage revealed no difference (Odds ratio [OR], 1.222; 95% Confidential interval [CI]: 0.615-2.427, p = 0.567). Conservative management had a higher risk of recurrence than surgery without statistical significance (OR 0.278, 95% CI: 0.109-0.707, p = 0.007). Compared with incision/drainage, surgery can prevent recurrence remarkably (OR 4.360, 95% CI: 1.761-10.792, p = 0.001). Subgroup analysis of different approaches within conservative treatment and operation was not performed for lacking information. CONCLUSION: Strong recommendations cannot be made due to the lack of prospective or randomized controlled studies. However, the current study based on real primary management supports initial surgical intervention for pediatric patients with perianal abscesses and anal fistula to prevent recurrence. LEVEL OF EVIDENCE: Type of study: Systemic review; Evidence level: Level II.", "provenance": [ { "field": "n", "quote": "Thirty-one studies involving 2507 pediatric patients met the inclusion criteria." }, { "field": "population", "quote": "patient age of <18 years" }, { "field": "intervention", "quote": "initial surgical intervention for pediatric patients with perianal abscesses and anal fistula" }, { "field": "comparator", "quote": "Compared with incision/drainage, surgery can prevent recurrence remarkably" }, { "field": "primaryOutcome", "quote": "Meta-analyses for recurrence after initial management were performed with a random-effects model." }, { "field": "result", "quote": "Compared with incision/drainage, surgery can prevent recurrence remarkably (OR 4.360, 95% CI: 1.761-10.792, p = 0.001)." }, { "field": "result", "quote": "Conservative management had a higher risk of recurrence than surgery without statistical significance (OR 0.278, 95% CI: 0.109-0.707, p = 0.007)." } ] }, { "id": "pmid:36589625", "pmid": "36589625", "doi": "10.3389/fsurg.2022.1065466", "nctId": null, "pmcid": "PMC9797814", "title": "Risk factors for therapy failure after surgery for perianal abscess in children", "firstAuthor": "Doerner", "multipleAuthors": true, "journal": "Front Surg", "year": 2022, "design": "retrospective", "n": 103, "nField": "reported", "population": "children under 14 who had surgery for a perianal abscess", "intervention": "fistula probing (and fistulotomy if a fistula was found) during abscess surgery", "comparator": "abscess surgery without fistula probing", "primaryOutcome": "recurrence of perianal abscess or development of anal fistula", "result": "fistula probing was linked to treatment success; prior history of perianal abscess was linked to treatment failure", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this is a retrospective study without randomization, so other factors could explain the link between fistula probing and better outcomes", "directness": "direct", "relevanceNote": "", "limitations": "retrospective design, no randomization, and comparisons based on univariate and multivariate statistics rather than controlled trial", "followUp": "", "plainFinding": "Fistula probing linked to fewer recurrences.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36589625/", "sourceText": "PURPOSE: The role of surgery in managing perianal abscesses in the pediatric population is debatable, and data on recurrence risk is rare. This study aimed to evaluate the efficiency of surgery for a perianal abscess in children and identify parameters that predict recurrence. METHODS: We performed a retrospective review of all children younger than age 14 requiring surgery for a perianal abscess from 2000 to 2018. RESULTS: Out of 103 enrolled patients, 27 (26%) had recurrent perianal disease. Recurrences appeared after a median of 5 months (range: 1-18 months), in 12 cases as perianal abscess and 15 cases as fistula in ano. Anal fistula probing was performed in 33% of all patients, of which 16 (15%) underwent fistulotomy. In univariate analysis, older age (p = 0.034), fistula probing (p = 0.006) and fistulotomy (p = 0.009) was associated with treatment success. History of perianal abscess, multilocal occurrence, and the presence of enteric flora in wound swabs was associated with treatment failure (p = 0.002, OR = 0.032). In multivariate analysis, anal fistula probing was independently associated with treatment success (p = 0.019, OR = 22.08), while the history of perianal abscess was associated with treatment failure (p = 0.002, OR = 0.032). CONCLUSION: Our study identified probing for fistula as a predictor of therapy success, while the history of perianal abscess was identified as a predictor of treatment failure. Therefore, in all children with perianal abscess, fistula probing and if present, fistulotomy should be performed.", "provenance": [ { "field": "population", "quote": "We performed a retrospective review of all children younger than age 14 requiring surgery for a perianal abscess from 2000 to 2018." }, { "field": "intervention", "quote": "Anal fistula probing was performed in 33% of all patients, of which 16 (15%) underwent fistulotomy." }, { "field": "comparator", "quote": "Anal fistula probing was performed in 33% of all patients" }, { "field": "primaryOutcome", "quote": "27 (26%) had recurrent perianal disease" }, { "field": "result", "quote": "In multivariate analysis, anal fistula probing was independently associated with treatment success (p = 0.019, OR = 22.08), while the history of perianal abscess was associated with treatment failure (p = 0.002, OR = 0.032)." }, { "field": "n", "quote": "Out of 103 enrolled patients, 27 (26%) had recurrent perianal disease." } ] }, { "id": "pmid:36351727", "pmid": "36351727", "doi": "10.1136/bmjopen-2022-067970", "nctId": null, "pmcid": "PMC9644350", "title": "Antibiotic Treatment foLlowing surgical drAinage of perianal abScess (ATLAS): protocol for a multicentre, double-blind, placebo-controlled, randomised trial", "firstAuthor": "van Oostendorp", "multipleAuthors": true, "journal": "BMJ Open", "year": 2022, "design": "registered-trial-no-results", "n": 298, "nField": "reported", "population": "adults with a perianal abscess after surgical drainage", "intervention": "antibiotics (ciprofloxacin and metronidazole) added to surgical drainage", "comparator": "surgical drainage alone plus placebo", "primaryOutcome": "development of an anal fistula within 1 year", "result": "no results yet, this is a trial protocol", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is only a planned trial with no outcomes reported yet", "directness": "direct", "relevanceNote": "", "limitations": "study has not yet reported results; only protocol described", "followUp": "1 year", "plainFinding": "Trial planned, no results yet", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36351727/", "sourceText": "INTRODUCTION: Perianal fistula is a burdening disease with an annual incidence of 6-12/100 000 in Western countries. More than 90% of crypto-glandular fistulas originate from perianal abscess. Despite adequate drainage, up to 83% recur or result in an anal fistula, the majority developing within 12 months. There is some evidence that gut-derived bacteria play a role in the development of perianal fistula. Up till now, it is not common practice to routinely administer prophylactic antibiotics to prevent anal fistula development. There is a need for a study to establish whether adding antibiotic treatment to surgical drainage of perianal abscess results in a reduction in perianal fistulas. METHODS AND ANALYSIS: This multicentre, double-blind, randomised, placebo-controlled trial investigates whether addition of antibiotics (ciprofloxacin and metronidazole) to surgical drainage of a perianal abscess is beneficial compared with surgical drainage alone. The primary outcome is the development of a perianal fistula within 1 year. Secondary outcomes include quality of life, treatment costs, need for repeated drainage, patient-reported outcomes and other clinical outcomes. Participants are recruited in one academic and seven peripheral Dutch clinics. To demonstrate a reduction of perianal fistula from 30% to 15% when treated with adjuvant antibiotics with a two-sided alpha of 0.05, a power of 80% and taking a 10% loss to follow-up percentage into account, the total sample size will be 298 participants. Data will be analysed according to the intention-to-treat principle. ETHICS AND DISSEMINATION: The study protocol has been approved by the Medical Ethics Review Committee of the Amsterdam University Medical Centers (nr. 2021_010). Written consent is obtained from each participant prior to randomisation into the study. The results of this trial will be submitted for publication in international peer-reviewed journals, presented at conferences and spread to coloproctological associations. TRIAL REGISTRATION NUMBERS: 2020-004449-35; NCT05385887.", "provenance": [ { "field": "n", "quote": "the total sample size will be 298 participants" }, { "field": "population", "quote": "surgical drainage of perianal abscess" }, { "field": "intervention", "quote": "addition of antibiotics (ciprofloxacin and metronidazole) to surgical drainage of a perianal abscess" }, { "field": "comparator", "quote": "surgical drainage alone" }, { "field": "primaryOutcome", "quote": "The primary outcome is the development of a perianal fistula within 1 year." }, { "field": "result", "quote": "The results of this trial will be submitted for publication in international peer-reviewed journals" } ] }, { "id": "pmid:35929816", "pmid": "35929816", "doi": "10.1093/bjs/znac225", "nctId": null, "pmcid": "PMC10364677", "title": "Postoperative Packing of Perianal Abscess Cavities (PPAC2): randomized clinical trial", "firstAuthor": "Newton", "multipleAuthors": true, "journal": "Br J Surg", "year": 2022, "design": "rct", "n": 433, "nField": "reported", "population": "adults having surgery to drain a perianal abscess", "intervention": "not packing the wound after drainage", "comparator": "packing the wound after drainage", "primaryOutcome": "pain level after surgery", "result": "Non-packing caused less pain and did not increase fistula or abscess recurrence rates", "resultDirection": "mixed", "quality": "moderate", "qualityWhy": "Large multicentre randomized trial with blinded outcome assessment, but fistula and recurrence differences were not statistically significant so those findings are less certain.", "directness": "direct", "relevanceNote": "", "limitations": "Fistula and recurrence differences between groups were not statistically significant (P = 0.20 for both)", "followUp": "6 months", "plainFinding": "Fewer fistulas with no wound packing", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/35929816/", "sourceText": "BACKGROUND: Perianal abscess is common. Traditionally, postoperative perianal abscess cavities are managed with internal wound packing, a practice not supported by evidence. The aim of this randomized clinical trial (RCT) was to assess if non-packing is less painful and if it is associated with adverse outcomes. METHODS: The Postoperative Packing of Perianal Abscess Cavities (PPAC2) trial was a multicentre, RCT (two-group parallel design) of adult participants admitted to an NHS hospital for incision and drainage of a primary perianal abscess. Participants were randomized 1:1 (via an online system) to receive continued postoperative wound packing or non-packing. Blinded data were collected via symptom diaries, telephone, and clinics over 6 months. The objective was to determine whether non-packing of perianal abscess cavities is less painful than packing, without an increase in perianal fistula or abscess recurrence. The primary outcome was pain (mean maximum pain score on a 100-point visual analogue scale). RESULTS: Between February 2018 and March 2020, 433 participants (mean age 42 years) were randomized across 50 sites. Two hundred and thirteen participants allocated to packing reported higher pain scores than 220 allocated to non-packing (38.2 versus 28.2, mean difference 9.9; P < 0.0001). The occurrence of fistula-in-ano was low in both groups: 32/213 (15 per cent) in the packing group and 24/220 (11 per cent) in the non-packing group (OR 0.69, 95 per cent c.i. 0.39 to 1.22; P = 0.20). The proportion of patients with abscess recurrence was also low: 13/223 (6 per cent) in the non-packing group and 7/213 (3 per cent) in the packing group (OR 1.85, 95 per cent c.i. 0.72 to 4.73; P = 0.20). CONCLUSION: Avoiding abscess cavity packing is less painful without a negative morbidity risk. REGISTRATION NUMBER: ISRCTN93273484 (https://www.isrctn.com/ISRCTN93273484). REGISTRATION NUMBER: NCT03315169 (http://clinicaltrials.gov).", "provenance": [ { "field": "n", "quote": "433 participants (mean age 42 years) were randomized across 50 sites" }, { "field": "population", "quote": "adult participants admitted to an NHS hospital for incision and drainage of a primary perianal abscess" }, { "field": "intervention", "quote": "non-packing" }, { "field": "comparator", "quote": "continued postoperative wound packing" }, { "field": "primaryOutcome", "quote": "The primary outcome was pain (mean maximum pain score on a 100-point visual analogue scale)." }, { "field": "result", "quote": "The occurrence of fistula-in-ano was low in both groups: 32/213 (15 per cent) in the packing group and 24/220 (11 per cent) in the non-packing group (OR 0.69, 95 per cent c.i. 0.39 to 1.22; P = 0.20)." } ] }, { "id": "pmid:35647894", "pmid": "35647894", "doi": "10.1089/sur.2021.351", "nctId": null, "pmcid": "PMC9208854", "title": "Intermediate-Term Evaluation of Initial Non-Surgical Management of Pediatric Perianal Abscess and Fistula-In-Ano", "firstAuthor": "Kang", "multipleAuthors": true, "journal": "Surg Infect (Larchmt)", "year": 2022, "design": "retrospective", "n": 457, "nField": "reported", "population": "children with a first-time perianal abscess and/or fistula-in-ano", "intervention": "non-surgical management of the abscess/fistula", "comparator": "surgical incision and/or drainage", "primaryOutcome": "rates of abscess recurrence and fistula-in-ano formation", "result": "no difference between non-surgical and surgical groups in recurrence or fistula formation rates", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "This is a retrospective study comparing treatment groups without randomization, so differences in how patients were selected for each treatment could affect the results.", "directness": "direct", "relevanceNote": "", "limitations": "Retrospective design comparing non-randomized groups; no information given on confounding factors or how treatment assignment was decided.", "followUp": "", "plainFinding": "No difference in fistula formation.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/35647894/", "sourceText": "Background: Non-surgical intervention has been proposed for the management of perianal abscess (PA) and fistula-in-ano (FIA), with potential benefits in terms of quality of life, wound healing, and functional outcome, although this strategy remains rare and controversial. Here, we aimed to compare the intermediate-term outcomes of non-surgical management with those of surgical incision and/or drainage. Patients and Methods: A study of pediatric patients with first-time PA and/or FIA was conducted retrospectively from January 2010 to December 2020. The patient population was stratified by surgical and non-surgical management. The clinical outcomes, including PA recurrence, FIA formation, and wound healing time, were compared between the surgical and non-surgical management groups. Results: A total of 457 patients managed for first-time PA and/or FIA were eligible for the current study. Of these patients, 169 (50.9%) patients received non-surgical intervention. There were no differences in terms of age, gender distribution, wound healing course, or abscess size between the two groups. Furthermore, no difference was noted between the two groups in terms of PA recurrence and/or FIA development rates and revisits for additional treatment. Conclusions: Although PA/FIA management is still controversial, non-surgical intervention exhibited promising outcomes for most cases of first-time PA/FIA, with fewer hospital admissions and surgical procedures and similar recurrence and fistula formation incidences. Immediate surgical intervention might be avoided because PA/FIA has a chance for spontaneous resolution in children.", "provenance": [ { "field": "n", "quote": "A total of 457 patients managed for first-time PA and/or FIA were eligible for the current study." }, { "field": "population", "quote": "A study of pediatric patients with first-time PA and/or FIA was conducted retrospectively" }, { "field": "intervention", "quote": "Of these patients, 169 (50.9%) patients received non-surgical intervention." }, { "field": "comparator", "quote": "compare the intermediate-term outcomes of non-surgical management with those of surgical incision and/or drainage" }, { "field": "primaryOutcome", "quote": "including PA recurrence, FIA formation, and wound healing time, were compared between the surgical and non-surgical management groups" }, { "field": "result", "quote": "no difference was noted between the two groups in terms of PA recurrence and/or FIA development rates and revisits for additional treatment" } ] }, { "id": "pmid:34876366", "pmid": "34876366", "doi": "10.1016/j.cireng.2021.11.012", "nctId": null, "pmcid": null, "title": "Recurrence and incidence of fistula after urgent drainage of an anal abscess. Long-term results", "firstAuthor": "Chaveli Díaz", "multipleAuthors": true, "journal": "Cir Esp (Engl Ed)", "year": 2022, "design": "retrospective", "n": 303, "nField": "reported", "population": "patients who had emergency drainage of an anal abscess", "intervention": "urgent drainage and debridement of the abscess", "comparator": "none (single cohort followed over time)", "primaryOutcome": "rate of recurrence and development of fistula after abscess drainage", "result": "About half of patients had recurrence and 40% developed a fistula", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a retrospective, single-cohort study without a comparison group, so it describes what happens after drainage rather than testing a way to prevent fistula.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective design, no comparator group or tested preventive intervention, reliance on ultrasound and symptom review which may miss or overcall fistula.", "followUp": "119.7 months", "plainFinding": "Fistula common after abscess drainage.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34876366/", "sourceText": "INTRODUCTION: Anal abscess is the most frequent urgent proctological problem. The recurrence rate and reported incidence of fistula after drainage and debridement of an anal abscess is widely variable. The objective of this study is to analyse the long-term recurrence rate and the incidence of fistula after drainage and urgent debridement of an anal abscess. METHODS: Retrospective observational study of a prospective cohort with anal abscess of cryptoglandular origin. All patients (n = 303) were evaluated two months and one year after the intervention. At the 5th year, all the medical records were reviewed and a telephone call or appointment was made for an assessment if necessary. Specific antecedents of anal pathology, abscess characteristics, time and type of recurrence, presence of symptoms in the first revision and presence of clinical and/or ultrasound fistula were recorded. RESULTS: Mean follow-up 119.7 months. Recurrence rate 48.2% (82.2% in the first year). Two hundred twenty-two ultrasounds performed. Incidence of ultrasound fistula: 70% symptomatic vs. 2.4% asymptomatic (p < 0.001). Global incidence of fistula 40.3%. The history of anal pathology and the presence of symptoms in the postoperative review significantly increase the possibility of recurrence (p < 0.001). The fistula is statistically more frequent if the abscess recurs (p < 0.001). CONCLUSION: After drainage and debridement of an anal abscess, half of the patients relapse and 40% develop fistula especially in the first year, so longer follow-ups are not necessary. Endoanal ultrasound for the evaluation of the presence of fistula is highly questionable in the absence of signs or symptoms.", "provenance": [ { "field": "n", "quote": "All patients (n = 303) were evaluated two months and one year after the intervention." }, { "field": "population", "quote": "anal abscess of cryptoglandular origin" }, { "field": "intervention", "quote": "drainage and urgent debridement of an anal abscess" }, { "field": "comparator", "quote": "Retrospective observational study of a prospective cohort" }, { "field": "primaryOutcome", "quote": "analyse the long-term recurrence rate and the incidence of fistula after drainage and urgent debridement of an anal abscess" }, { "field": "result", "quote": "Recurrence rate 48.2% (82.2% in the first year)." }, { "field": "result", "quote": "Global incidence of fistula 40.3%." } ] }, { "id": "pmid:34628909", "pmid": "34628909", "doi": "10.21037/apm-21-2229", "nctId": null, "pmcid": null, "title": "A systematic review and meta-analysis of incision and seton drainage in the treatment of high perianal abscess", "firstAuthor": "Shi", "multipleAuthors": true, "journal": "Ann Palliat Med", "year": 2021, "design": "meta-analysis", "n": null, "nField": "not-reported", "population": "people with high perianal abscess", "intervention": "incision and seton drainage surgery", "comparator": "incision and drainage surgery alone", "primaryOutcome": "cure rate, wound healing time, fistula formation, abscess recurrence, and complications", "result": "incision-seton drainage had higher cure rates, shorter healing time, lower pain and continence scores, lower fistula formation and recurrence rates, fewer adverse events, and shorter hospital stay than incision-drainage alone", "resultDirection": "benefit", "quality": "low", "qualityWhy": "it pools multiple small trials of unclear individual quality and the authors themselves say there are gaps in the evidence and more high-quality trials are needed", "directness": "direct", "relevanceNote": "", "limitations": "the abstract notes the meta-analysis still leaves gaps in the evidence and calls for more large-sample, high-quality, multi-center RCTs", "followUp": "", "plainFinding": "Fewer fistulas with seton drainage.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34628909/", "sourceText": "BACKGROUND: Surgery is the clinically preferred treatment for high perianal abscesses. Incision and seton drainage improve the cure rate and reduce recurrence. We aimed to systematically evaluate the clinical effect and safety of incision and seton drainage in the treatment of high perianal abscess. METHODS: China Knowledge Network (CNKI), WanFang database, VIP database, PubMed, and Cochrane Library were searched and all relevant Chinese and English language documents until July 2021were retrieved. All records that described randomized clinical trials (RCTs) of incision and seton drainage for the treatment of high perianal abscess were eligible. Documents that met the inclusion criteria were evaluated for bias using the Cochrane Collaboration Risk Evaluation Standard, and Revman5.4 software was used to analyze the data. RESULTS: Fourteen RCTs were included. The results of nine studies showed that the clinical cure rate of the incision-seton group was higher than that of the incision-drainage group (P<0.05). Seven studies showed that the wound healing time of the incision-seton group was shorter than that of the incision-drainage group (P<0.05). Four studies showed that the visual analogue scale (VAS) score of the incision-seton group was lower than that of the incision-drainage group (P<0.05). Five studies showed that the Wexner score of the incision-seton group was lower than that of the incision-drainage group (P<0.05). Six studies showed that the formation rate of anal fistula in the incision-seton group was lower than that in the incision-drainage group (P<0.05). Six studies demonstrated that the recurrence rate of abscess in the incision-seton group was lower than that in the incision-drainage group (P<0.05). Seven studies showed that the incidence of adverse events in the incision-seton group was lower than that in the incision-drainage group (P<0.05). Five studies demonstrated that the length of stay in the incision-seton group was shorter than that of the incision-drainage group (P<0.05). DISCUSSION: The choice of surgical methods in clinical research has always been controversial. The incision-seton method can effectively and safely treat high perianal abscess. However, the results of this meta-analysis still leave some gaps in the evidence. More large-sample, high-quality, and multi-center RCTs are needed.", "provenance": [ { "field": "population", "quote": "high perianal abscess" }, { "field": "intervention", "quote": "incision and seton drainage" }, { "field": "comparator", "quote": "incision-drainage group" }, { "field": "primaryOutcome", "quote": "the formation rate of anal fistula in the incision-seton group was lower than that in the incision-drainage group" }, { "field": "result", "quote": "Six studies showed that the formation rate of anal fistula in the incision-seton group was lower than that in the incision-drainage group (P<0.05)." }, { "field": "limitations", "quote": "the results of this meta-analysis still leave some gaps in the evidence. More large-sample, high-quality, and multi-center RCTs are needed." } ] }, { "id": "pmid:34376025", "pmid": "34376025", "doi": "10.3393/ac.2020.00962.0137", "nctId": null, "pmcid": "PMC10009068", "title": "Incidence of anal fistula after pyogenic perianal abscess drainage in Kingdom of Bahrain", "firstAuthor": "Hasan", "multipleAuthors": true, "journal": "Ann Coloproctol", "year": 2023, "design": "retrospective", "n": 109, "nField": "reported", "population": "adults diagnosed with perianal abscess in Bahrain", "intervention": "abscess drainage", "comparator": "", "primaryOutcome": "development of anal fistula after abscess drainage", "result": "About 1 in 3 patients developed a fistula after abscess drainage", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a retrospective study without a comparison group, so it cannot show whether anything prevents fistula formation.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective design; data partly collected via phone calls; no comparison of preventive interventions.", "followUp": "", "plainFinding": "About a third developed fistula.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34376025/", "sourceText": "PURPOSE: Perianal fistula is one of the most common anorectal diseases in adult patients, especially men. A relationship between pyogenic perianal abscess and fistula formation is established in multiple domains. This is the first exploration of such association among patients in the country as no related study has been published in Bahrain. We expect this study to be a foundation for future protocols and evidence-based practice. METHODS: A retrospective study was conducted in Salmaniya Medical Complex of Bahrain. A total of 109 patients with a diagnosis of anal abscess were included between 2015 and 2018. Data were collected from the electronic files database used in Salmaniya Medical Complex (iSeha) as well as phone calls to the patients. Collected data were analyzed using statistical software. RESULTS: The most predominant presentation of perianal abscess was pain. Over 50% of abscesses were classified as perianal (56.9%) and among those, left-sided abscesses were more common, followed by right-, posterior-, and anterior-sited, respectively. No recurrence of abscess was recorded among 80% of patients. A fistula developed following abscess drainage in 33.9% of patients. Most fistulas (37.8%) were diagnosed within 6 months or less from abscess drainage. Posterior fistulas were the most common, followed by anterior and left-sided fistulas. CONCLUSION: The incidence of anal fistula in Bahrain after perianal abscess was 33.9%. Most of the patients who developed a fistula following pyogenic abscess drainage were males and above the age of 40 years. The most common site for fistula was posterior.", "provenance": [ { "field": "n", "quote": "A total of 109 patients with a diagnosis of anal abscess were included between 2015 and 2018." }, { "field": "population", "quote": "patients with a diagnosis of anal abscess" }, { "field": "intervention", "quote": "A fistula developed following abscess drainage in 33.9% of patients." }, { "field": "primaryOutcome", "quote": "A fistula developed following abscess drainage in 33.9% of patients." }, { "field": "result", "quote": "The incidence of anal fistula in Bahrain after perianal abscess was 33.9%." } ] }, { "id": "pmid:33447866", "pmid": "33447866", "doi": "10.1007/s00384-021-03845-6", "nctId": null, "pmcid": null, "title": "Needle aspiration treatment vs. incision of acute simple perianal abscess: randomized controlled study", "firstAuthor": "Sørensen", "multipleAuthors": true, "journal": "Int J Colorectal Dis", "year": 2021, "design": "rct", "n": 98, "nField": "reported", "population": "adults with an acute perianal abscess", "intervention": "needle aspiration of the abscess plus a week of antibiotics (clindamycin)", "comparator": "conventional surgical incision and drainage of the abscess", "primaryOutcome": "abscess coming back (recurrence)", "result": "abscess recurrence was higher with needle aspiration (41%) than with incision drainage (15%); fistula formation was 15% with no significant difference between groups", "resultDirection": "harm", "quality": "moderate", "qualityWhy": "it was a randomized trial across three centers, but had a modest number of patients which limits certainty, especially for the less common fistula outcome.", "directness": "direct", "relevanceNote": "", "limitations": "abstract does not report blinding, and fistula formation subgroup difference may be underpowered given the overall sample size", "followUp": "52 weeks", "plainFinding": "No fewer fistulas; more recurrence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33447866/", "sourceText": "PURPOSE: Needle aspiration of an acute simple perianal abscess may be an alternative to conventional incision drainage with potential advantages in wound healing, functional outcome, and quality of life. The aim and objectives of the study are to compare the outcome of needle aspiration and postoperative antibiotics with that of conventional surgical incision drainage of acute perianal abscess. The primary outcome was abscess recurrence. Secondary outcomes were fistula formation, wound healing, quality of life, and fecal continence. METHODS: This is a three-center randomized controlled trial, including adults with acute perianal abscess. The needle aspiration group received clindamycin for one week postoperatively. All included patients were scheduled for a follow-up at 2, 12, and 52 weeks postoperatively including physical examination, quality of life assessment (SF 36 questionnaire), and fecal continence (Wexner score). RESULTS: A total of 98 patients were included. The recurrence rate was 41% in needle aspiration and 15% in incision drainage, with HR of 3.033 (p = 0.014). Fistula formation was 15% without significant difference between the groups. There was no significant difference in wound healing, quality of life, or fecal incontinence scores. CONCLUSION: Needle aspiration with postoperative antibiotics cannot be recommended as an alternative for surgical incision in the treatment of acute perianal abscess. TRIAL REGISTRATION NUMBER: ClinicalTrials.org with identification number NCT02585141, initial release on 15 October 2015.", "provenance": [ { "field": "population", "quote": "adults with acute perianal abscess" }, { "field": "intervention", "quote": "The needle aspiration group received clindamycin for one week postoperatively" }, { "field": "comparator", "quote": "conventional surgical incision drainage of acute perianal abscess" }, { "field": "primaryOutcome", "quote": "The primary outcome was abscess recurrence." }, { "field": "result", "quote": "The recurrence rate was 41% in needle aspiration and 15% in incision drainage, with HR of 3.033 (p = 0.014). Fistula formation was 15% without significant difference between the groups." }, { "field": "n", "quote": "A total of 98 patients were included." }, { "field": "followUp", "quote": "follow-up at 2, 12, and 52 weeks postoperatively" } ] }, { "id": "pmid:33254180", "pmid": "33254180", "doi": "10.24875/CIRU.20000926", "nctId": null, "pmcid": null, "title": "Urgent care practice in anorectal abscess. Still a pending task", "firstAuthor": "Arroyo-Martinez", "multipleAuthors": true, "journal": "Cir Cir", "year": 2020, "design": "retrospective", "n": 190, "nField": "reported", "population": "adults who had surgery for anorectal abscess in the emergency department", "intervention": "different emergency department treatments (drainage, antibiotics, referral to specialist clinic)", "comparator": "no formal comparison group - treatments and outcomes compared across patients", "primaryOutcome": "recurrence of the abscess", "result": "the only factor linked to recurrence was having an associated anal fistula, and antibiotics or referral practices showed no clear effect on recurrence", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a retrospective, single-center study without a controlled comparison, so it cannot show whether any treatment actually prevents fistula formation.", "directness": "indirect", "relevanceNote": "", "limitations": "retrospective design, single center, great variability in treatment practices, no randomization or control group", "followUp": "", "plainFinding": "No clear way found to prevent fistula.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33254180/", "sourceText": "AIM: The aim of the study was to evaluate urgent care practice with regard to anorectal abscesses (AA) in a tertiary-level referral hospital. MATERIALS AND METHODS: this was retrospective and unicentric study. Patients who underwent surgery for AA between 2016 and 2017 were included in the study. Demographic variables were analyzed as well as the treatment performed, the need for hospitalization, use of antibiotics, and referral to the coloproctology outpatient department (COD). The recurrence risk factors were also evaluated. RESULTS: A total of 220 evaluations under anesthesia were performed, corresponding to 190 patients, 129 males (mean age 46 ± 14.9 years). The most frequent treatment in the emergency department (ED) was simple drainage (75.8%). Antibiotic therapy was prescribed in 62.9% of the cases. A total of 41.1% of the patients were referred to a specialized COD. The only risk factor associated with recurrence was the presence of an associated anal fistula. CONCLUSIONS: Anorectal abscesses are very frequent in the ED. There is great clinical variability regarding the taking of cultures, prescription of antibiotics, and referral criteria to a specialized coloproctology outpatient department, without clear impact of any of them on the recurrence of the abscess.", "provenance": [ { "field": "n", "quote": "corresponding to 190 patients, 129 males (mean age 46 ± 14.9 years)" }, { "field": "population", "quote": "Patients who underwent surgery for AA between 2016 and 2017 were included in the study." }, { "field": "intervention", "quote": "The most frequent treatment in the emergency department (ED) was simple drainage (75.8%). Antibiotic therapy was prescribed in 62.9% of the cases." }, { "field": "comparator", "quote": "this was retrospective and unicentric study." }, { "field": "primaryOutcome", "quote": "The recurrence risk factors were also evaluated." }, { "field": "result", "quote": "The only risk factor associated with recurrence was the presence of an associated anal fistula." }, { "field": "result", "quote": "without clear impact of any of them on the recurrence of the abscess." } ] }, { "id": "pmid:33023436", "pmid": "33023436", "doi": "10.2174/1574887115999201006201926", "nctId": null, "pmcid": null, "title": "Ligasure Hemorrhoidectomy: Updates on Complications After an 18-Year Experience", "firstAuthor": "Rho", "multipleAuthors": true, "journal": "Rev Recent Clin Trials", "year": 2021, "design": "case-series", "n": 1454, "nField": "reported", "population": "adults with grade III and IV hemorrhoids undergoing surgery", "intervention": "LigaSure hemorrhoidectomy (a sealing-device hemorrhoid removal surgery)", "comparator": "none - single group followed over time", "primaryOutcome": "rate of post-operative complications including anal fistula, stenosis, bleeding, and recurrence", "result": "anal fistula occurred in 0.2% of patients as a long-term complication after this hemorrhoid surgery", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single-center descriptive case series with no comparison group, so it cannot show whether anything actually prevents fistula formation.", "directness": "indirect", "relevanceNote": "", "limitations": "no control group, not designed to test fistula prevention, single center, descriptive only", "followUp": "", "plainFinding": "Very low fistula rate after surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33023436/", "sourceText": "BACKGROUND: Hemorrhoidal disease represents one of the most common anorectal disorders in the general population. Energy devices, such as LigaSureTM scalpel, have reshaped the concept of hemorrhoid surgery and in turn, have improved patient outcomes and simplified the work of surgeon. OBJECTIVE: The study aims to evaluate the outcomes of LigaSureTM hemorrhoidectomy (LH) analyzing main post-operative complications rate, length of stay, operating time, and time to return to work. METHODS: In this monocentric descriptive study, from June 2001 to February 2019, 1454 consecutive patients, treated with LH for grade III and IV hemorrhoids, were analyzed. Complications were classified in early, late, and long-term if they occurred within 1 month, between 1 and 2 months or after 2 months, respectively. RESULTS: 90.2% of patients were treated in day surgery regimen and the mean operating time was 14.3 minutes. The post-operative pain decreased from 3.7 mean VAS on the 1st postoperative day to 0.1 mean VAS on 30th post-operative day. Early complications rate was 2.1%: urinary retention accounted for 1.8% of patients. 0.3%-of patients experienced postoperative bleeding and only one required reoperation. Late complications rate was 5.8%: anal stenosis, incomplete healing, and anal fissure were detected in 3.6%, 1.2%, and 1% of patients, respectively. The long term complications rate was 5.3%: anal fistula, soiling, perianal abscess, and recurrence were identified in 0.2%, 0.1%, 0.3%, and 4.8% of patients, respectively. CONCLUSION: LH is a safe and fast procedure with a proven minimal complication rate.", "provenance": [ { "field": "n", "quote": "1454 consecutive patients, treated with LH for grade III and IV hemorrhoids, were analyzed" }, { "field": "population", "quote": "1454 consecutive patients, treated with LH for grade III and IV hemorrhoids" }, { "field": "intervention", "quote": "LigaSureTM hemorrhoidectomy (LH)" }, { "field": "comparator", "quote": "In this monocentric descriptive study, from June 2001 to February 2019, 1454 consecutive patients, treated with LH for grade III and IV hemorrhoids, were analyzed." }, { "field": "primaryOutcome", "quote": "evaluate the outcomes of LigaSureTM hemorrhoidectomy (LH) analyzing main post-operative complications rate" }, { "field": "result", "quote": "anal fistula, soiling, perianal abscess, and recurrence were identified in 0.2%, 0.1%, 0.3%, and 4.8% of patients, respectively" } ] }, { "id": "pmid:32935802", "pmid": "32935802", "doi": "10.1590/1806-9282.66.8.1082", "nctId": null, "pmcid": null, "title": "Can the risk of anal fistula development after perianal abscess drainage be reduced?", "firstAuthor": "Gokce", "multipleAuthors": true, "journal": "Rev Assoc Med Bras (1992)", "year": 2020, "design": "retrospective", "n": null, "nField": "not-reported", "population": "patients who had a perianal abscess drained by surgery", "intervention": "in-hospital dressing changes with washing of the area until the abscess healed", "comparator": "dressing changes at home with 10% povidone-iodine sitz baths", "primaryOutcome": "development of an anal fistula after abscess drainage", "result": "fistula formation was significantly lower in the in-hospital washing and dressing group than in the home sitz-bath group", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a retrospective chart review, not a randomized trial, so other differences between groups could explain the result.", "directness": "direct", "relevanceNote": "", "limitations": "Retrospective review of records; authors state a large, prospective study is needed for confirmation.", "followUp": "", "plainFinding": "Hospital wound care cut fistula risk.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32935802/", "sourceText": "OBJECTIVE: Perianal abscesses are frequently seen in clinical practice, and perianal fistulas develop in 30%-50% of cases after treatment. This study investigated whether the type of dressing applied after abscess drainage is correlated with fistula development. Prevention of fistula formation would reduce both the loss of work and healthcare costs. METHODS: The records of patients who underwent drainage of perianal abscesses between January 2015 and January 2018 were retrospectively reviewed. Patients with postoperative dressings changed with washing of the area in the hospital were included as Group 1. Patients with dressings changed at home and the area bathed in 10% povidone-iodine sitz bath were included as Group 2. The frequency and time of fistula formation, age, sex, cost, and workdays lost in the two groups were compared. RESULTS: Between-group differences in age, sex, body mass index, and type of fistula that developed after months and 1 year of the abscess drainage were not statistically significant (p > 0.05). During follow-up, fistula development was significantly lower in Group 1 than in Group 2 (p < 0.001). The risk of perianal fistula development was significantly increased in those with a body mass index (BMI) > 30 (p = 0.004). CONCLUSIONS: After perianal abscess drainage, in-hospital washing and dressing of the abscess area until abscess closure reduced the risk of perianal fistula, lost work time, and cost. The risk of perianal fistula development appeared to increase with BMI. A large, prospective study is needed for confirmation.", "provenance": [ { "field": "population", "quote": "The records of patients who underwent drainage of perianal abscesses between January 2015 and January 2018 were retrospectively reviewed." }, { "field": "intervention", "quote": "Patients with postoperative dressings changed with washing of the area in the hospital were included as Group 1." }, { "field": "comparator", "quote": "Patients with dressings changed at home and the area bathed in 10% povidone-iodine sitz bath were included as Group 2." }, { "field": "primaryOutcome", "quote": "The frequency and time of fistula formation, age, sex, cost, and workdays lost in the two groups were compared." }, { "field": "result", "quote": "During follow-up, fistula development was significantly lower in Group 1 than in Group 2 (p < 0.001)." } ] }, { "id": "pmid:32785778", "pmid": "32785778", "doi": "10.1007/s00383-020-04728-7", "nctId": null, "pmcid": null, "title": "Management of perianal abscesses in infants without general anaesthesia: a systematic review of the literature", "firstAuthor": "Stokes", "multipleAuthors": true, "journal": "Pediatr Surg Int", "year": 2020, "design": "systematic-review", "n": 1049, "nField": "reported", "population": "infants less than 24 months old", "intervention": "treating the abscess without general anaesthesia (antibiotics, baths, needle draining, or local anaesthesia drainage)", "comparator": "no direct comparison group; outcomes compared to historical use of general anaesthesia", "primaryOutcome": "how many infants ended up needing general anaesthesia after initial non-GA treatment", "result": "75.3% healed completely without further treatment, 23.2% had recurrence or progressed to a fistula, and 5.6% eventually needed general anaesthesia", "resultDirection": "mixed", "quality": "low", "qualityWhy": "The review combines mostly retrospective studies with no randomized trials and no control group, so it cannot reliably show whether this approach prevents fistula formation.", "directness": "indirect", "relevanceNote": "", "limitations": "No randomized controlled trials, mostly retrospective cohort data, and a lack of standardized treatment or follow-up across studies.", "followUp": "", "plainFinding": "Most healed, some still got fistulas.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32785778/", "sourceText": "Perianal abscesses are a common surgical presentation in infants. Historically, general anaesthesia (GA) has been used to facilitate incision and drainage, with or without exploration for a fistula-in-ano (FIA). This review aims to assess outcomes following management of perianal abscesses without GA in infants less than 24 months old. We aim to identify the success of management without GA. Using PRISMA guidelines, studies were identified from MEDLINE, EMBASE and PubMed. Studies including infants less than 24 months with perianal abscesses managed without GA were reviewed. The primary outcome was the number of patients requiring GA following initial management without GA. Secondary outcomes included rates of recurrent perianal abscesses, rates of progression to FIA and time to cure. Nine studies, involving 1049 infants less than 24 months old met inclusion criteria. A total of 1039 (99.0%) were males. Study design consisted of one prospective case series of 18 patients, and eight retrospective cohort studies. There were no randomized control trials. A total of 1037 (98.9%) patients were initially managed without GA. Of these, 59 (5.6%) were documented to subsequently require a general anaesthetic. Treatment modalities included antibiotics, regular baths, needle aspiration, incision and drainage under local anaesthesia, hainosankyuto and fibroblast growth factor. A total of 790 (75.3%) healed primarily without further intervention. A total of 243 (23.2%) were documented to have a recurrence or progression to FIA. All patients who required a subsequent general anaesthetic had progressed to FIA. Despite the lack of well-designed prospective studies, existing evidence supports management of perianal abscesses without initial GA in infants, with more than 75% healing completely. Further research aimed at standardizing care and confirming the safety and efficacy of initial non-operative management are warranted, and may potentially reduce the number of unnecessary initial and subsequent clinical interventions.", "provenance": [ { "field": "population", "quote": "infants less than 24 months old" }, { "field": "intervention", "quote": "management of perianal abscesses without GA in infants less than 24 months old" }, { "field": "comparator", "quote": "Historically, general anaesthesia (GA) has been used to facilitate incision and drainage, with or without exploration for a fistula-in-ano (FIA)." }, { "field": "primaryOutcome", "quote": "The primary outcome was the number of patients requiring GA following initial management without GA." }, { "field": "result", "quote": "A total of 790 (75.3%) healed primarily without further intervention. A total of 243 (23.2%) were documented to have a recurrence or progression to FIA." }, { "field": "n", "quote": "Nine studies, involving 1049 infants less than 24 months old met inclusion criteria." } ] }, { "id": "pmid:32740696", "pmid": "32740696", "doi": "10.1007/s00423-020-01941-9", "nctId": null, "pmcid": null, "title": "Incision and drainage of cutaneous abscess with or without cavity packing: a systematic review, meta-analysis, and trial sequential analysis of randomised controlled trials", "firstAuthor": "Mohamedahmed", "multipleAuthors": true, "journal": "Langenbecks Arch Surg", "year": 2021, "design": "meta-analysis", "n": 485, "nField": "reported", "population": "patients with cutaneous abscess (including some with ano-rectal abscess) undergoing incision and drainage", "intervention": "incision and drainage without packing the abscess cavity", "comparator": "incision and drainage with packing the abscess cavity", "primaryOutcome": "development of fistula-in-ano, abscess recurrence, and need for second intervention", "result": "no significant difference in fistula formation, recurrence, or need for repeat treatment between packing and no packing", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "Pooled trials were few and small, and the analysis itself says the results were inconclusive and subject to error.", "directness": "indirect", "relevanceNote": "", "limitations": "Trial sequential analysis showed the meta-analysis was not conclusive and recurrence results were subject to type 2 error", "followUp": "maximum follow-up period", "plainFinding": "No difference in fistula risk.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32740696/", "sourceText": "AIMS: To evaluate comparative outcomes of incision and drainage of cutaneous abscess with and without packing of the abscess cavity. METHODS: A systematic search of multiple electronic data sources was conducted, and all randomised controlled trials (RCTs) comparing incision and drainage of cutaneous abscess with and without packing were included. Abscess recurrence at maximum follow-up period, need for second intervention, and development of fistula in-ano were the evaluated outcome parameters for the meta-analysis A Trial Sequential Analysis was conducted to determine the robustness of the findings. RESULTS: Eight RCTs reporting a total number of 485 patients who underwent incision and drainage of cutaneous abscess with (n = 243) or without (n = 242) packing of the abscess cavity were included. There was no significant difference in the risk of recurrence (risk ratio (RR) 1.31, P = 0.56), fistula-in-ano (RR 0.63, P = 0.28), and need for second intervention (RR 0.70, P = 0.05) between two groups. The results remained unchanged on sub-group analyses for ano-rectal abscess, paediatric patients, adult patients, and the use of antibiotics. The Trial Sequential Analysis demonstrated that the meta-analysis was not conclusive, and the results for recurrence were subject to type 2 error. CONCLUSION: Incision and drainage of cutaneous abscess with or without packing have comparable outcomes. However, considering the cost and post-operative pain associated with packing, performing the procedure without packing of the abscess cavity may be more favourable. The findings of the better quality ongoing RCTs may provide stronger evidence in favour of packing or non-packing.", "provenance": [ { "field": "n", "quote": "Eight RCTs reporting a total number of 485 patients who underwent incision and drainage of cutaneous abscess with (n = 243) or without (n = 242) packing of the abscess cavity were included." }, { "field": "population", "quote": "all randomised controlled trials (RCTs) comparing incision and drainage of cutaneous abscess with and without packing" }, { "field": "intervention", "quote": "incision and drainage of cutaneous abscess with and without packing of the abscess cavity" }, { "field": "comparator", "quote": "packing of the abscess cavity" }, { "field": "primaryOutcome", "quote": "Abscess recurrence at maximum follow-up period, need for second intervention, and development of fistula in-ano were the evaluated outcome parameters for the meta-analysis" }, { "field": "result", "quote": "There was no significant difference in the risk of recurrence (risk ratio (RR) 1.31, P = 0.56), fistula-in-ano (RR 0.63, P = 0.28), and need for second intervention (RR 0.70, P = 0.05) between two groups." }, { "field": "limitations", "quote": "The Trial Sequential Analysis demonstrated that the meta-analysis was not conclusive, and the results for recurrence were subject to type 2 error." } ] }, { "id": "pmid:32408417", "pmid": "32408417", "doi": "10.3345/cep.2019.00969", "nctId": null, "pmcid": "PMC7374001", "title": "Efficacy of conservative treatment of perianal abscesses in children and predictors for therapeutic failure", "firstAuthor": "Boenicke", "multipleAuthors": true, "journal": "Clin Exp Pediatr", "year": 2020, "design": "retrospective", "n": 113, "nField": "reported", "population": "children under 14 with perianal abscesses", "intervention": "conservative (non-surgical) treatment of perianal abscess", "comparator": "primary surgery for the abscess", "primaryOutcome": "whether treatment achieved permanent remission without recurrence or progression to fistula/surgery", "result": "Conservative treatment alone permanently worked in only 14 of 113 patients, with abscess size predicting failure; recurrence rates after surgery were similar whether surgery was done first or after failed conservative treatment", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "This is a retrospective chart review without randomization, so differences between groups could be due to other factors, not just treatment choice.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective design, no randomization, treatment choice not standardized, long variable follow-up for recurrence.", "followUp": "a median 34 months (range, 3 to 145 months)", "plainFinding": "Conservative treatment rarely cured abscess permanently.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32408417/", "sourceText": "BACKGROUND: The optimal management of perianal abscess in children is controversial. PURPOSE: To evaluate the efficiency of conservative treatment of perianal abscess in children and identify parameters that predict therapy failure. METHODS: All cases of children younger than 14 years of age with perianal abscesses between 2001-2016 were evaluated. RESULTS: Of the 113 enrolled patients, 64 underwent subsequent surgery for advanced disease (primary surgery group). Conservative treatment was initiated in 49 patients (primary conservative group) but was stopped because of inefficiency in 25 patients, who were referred for surgery after a median 7.03 days (range, 2 to 16 days). The other 24 patients (48%) initially achieved complete remission after conservative treatment, but 10 were readmitted after a median 34 months (range, 3 to 145 months) with recurrent disease. There were no significant differences in permanent success after conservative treatment between infants (10 of 29, 34%) and older children (4 of 20 [20%], P=0.122). Overall, conservative treatment alone was effective in only 14 of 113 patients. Recurrence after surgery occurred in 16 patients (25%) in the primary surgery group and 11 patients (22%) in the primary conservative group (P=0.75). Univariate analysis of predictors for conservative treatment failure revealed inflammatory values (C-reactive protein and white blood count, P=0.017) and abscess size (P=0.001) as significant parameters, whereas multivariate analysis demonstrated that only abscess size (odds ratio, 3.37; P=0.023) was significant. CONCLUSION: Conservative treatment of perianal abscess is permanently efficient in only a minority of children but is not associated with a higher recurrence rate after subsequent surgery. Abscess size is a predictor for therapy failure.", "provenance": [ { "field": "population", "quote": "All cases of children younger than 14 years of age with perianal abscesses between 2001-2016 were evaluated." }, { "field": "intervention", "quote": "Conservative treatment was initiated in 49 patients" }, { "field": "comparator", "quote": "64 underwent subsequent surgery for advanced disease (primary surgery group)" }, { "field": "primaryOutcome", "quote": "To evaluate the efficiency of conservative treatment of perianal abscess in children and identify parameters that predict therapy failure." }, { "field": "result", "quote": "Overall, conservative treatment alone was effective in only 14 of 113 patients." }, { "field": "result", "quote": "Recurrence after surgery occurred in 16 patients (25%) in the primary surgery group and 11 patients (22%) in the primary conservative group (P=0.75)." }, { "field": "result", "quote": "multivariate analysis demonstrated that only abscess size (odds ratio, 3.37; P=0.023) was significant" }, { "field": "n", "quote": "Of the 113 enrolled patients" }, { "field": "followUp", "quote": "a median 34 months (range, 3 to 145 months)" } ] }, { "id": "pmid:32341739", "pmid": "32341739", "doi": "10.11604/pamj.2020.35.18.21029", "nctId": null, "pmcid": "PMC7170736", "title": "Preventing the recurrence of acute anorectal abscesses utilizing a loose seton: a pilot study", "firstAuthor": "Erol", "multipleAuthors": true, "journal": "Pan Afr Med J", "year": 2020, "design": "prospective-cohort", "n": 44, "nField": "reported", "population": "patients with anorectal abscesses, some with possible fistula tracts", "intervention": "abscess drainage plus loose seton (or fistulotomy) for the fistula tract at the same operation", "comparator": "abscess drainage alone", "primaryOutcome": "recurrence of anorectal abscess at 12 months, plus continence and complications", "result": "No abscess recurrence after drainage plus loose seton or fistulotomy, versus 58.8% recurrence after drainage alone (p<0.0001), with similar continence scores before and after surgery", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a small, non-randomized pilot study without blinding, so the results are not strong enough to be fully trusted.", "directness": "indirect", "relevanceNote": "", "limitations": "Pilot study design, not randomized, small group sizes, and the primary outcome was abscess recurrence rather than fistula formation itself.", "followUp": "12 months", "plainFinding": "Fewer abscess recurrences with seton treatment.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32341739/", "sourceText": "INTRODUCTION: This pilot study aimed to document our results of treating anorectal abscesses with drainage plus loose seton for possible coexisting high fistulas or drainage plus fistulotomy for low tracts at the same operation. METHODS: Drainage plus fistulotomy were performed only in cases with subcutaneous mucosa, intersphincteric, or apparently low transsphincteric fistula tracts. For all other cases with high transsphincteric fistula or those with questionable sphincter involvement, a loose seton was placed through the tract. Drainage only was carried out in 17 patients. RESULTS: Twenty-three patients underwent drainage plus loose seton. Drainage plus fistulotomy were performed in four cases. None of the patients developed recurrent abscess during a follow-up of 12 months. Not surprisingly, the incontinence scores were similar pre and post-operatively (p=0.564). Only minor complications occurred in 4 cases (14.8 percent). Secondary interventions following loose seton were carried out in 13 patients (48.1 percent). At 12 months, drainage only was followed by 10 recurrences (58.8 percent; p<0.0001, compared with concomitant surgery). CONCLUSION: Concomitant loose seton treatment of high fistula tracts associated with anorectal abscess prevents abscess recurrence without significant complications or disturbance of continence. Concomitant fistulotomy for associated low fistulas also aids in the same clinical outcome. Concomitant fistula treatment with the loose seton may suffice in treating the whole disease process in selected cases. Even in patients with high fistula tracts, the loose seton makes fistula surgery simpler with a mature tract. Abscess recurrence is high after drainage only.", "provenance": [ { "field": "population", "quote": "treating anorectal abscesses with drainage plus loose seton for possible coexisting high fistulas or drainage plus fistulotomy for low tracts" }, { "field": "intervention", "quote": "Drainage plus fistulotomy were performed only in cases with subcutaneous mucosa, intersphincteric, or apparently low transsphincteric fistula tracts." }, { "field": "intervention", "quote": "a loose seton was placed through the tract" }, { "field": "comparator", "quote": "Drainage only was carried out in 17 patients." }, { "field": "n", "quote": "Drainage only was carried out in 17 patients." }, { "field": "n", "quote": "Twenty-three patients underwent drainage plus loose seton." }, { "field": "n", "quote": "Drainage plus fistulotomy were performed in four cases." }, { "field": "primaryOutcome", "quote": "None of the patients developed recurrent abscess during a follow-up of 12 months." }, { "field": "result", "quote": "At 12 months, drainage only was followed by 10 recurrences (58.8 percent; p<0.0001, compared with concomitant surgery)." }, { "field": "followUp", "quote": "follow-up of 12 months" } ] }, { "id": "pmid:32312918", "pmid": "32312918", "doi": "10.5604/01.3001.0013.8158", "nctId": null, "pmcid": null, "title": "Perianal abscess and fistula-in-ano in children - evaluation of treatment efficacy. Is it possible to avoid recurrence?", "firstAuthor": "Bałaż", "multipleAuthors": true, "journal": "Pol Przegl Chir", "year": 2020, "design": "retrospective", "n": 24, "nField": "reported", "population": "infants and children with perianal abscess", "intervention": "fistulotomy (surgically opening the fistula) after identifying the fistula during abscess surgery", "comparator": "minimally invasive treatment with sitz baths, antibiotics, and incision and drainage of the abscess", "primaryOutcome": "recurrence of perianal abscess or fistula, and fecal incontinence", "result": "No fecal incontinence or recurrence of perianal abscess were observed in any of our patients after fistulotomy, whereas the minimally invasive approach was associated with a high recurrence rate", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a small, retrospective study of only 24 children without randomization, so the findings are not strong evidence.", "directness": "direct", "relevanceNote": "", "limitations": "Retrospective design, small sample size, and no control group treated with only minimally invasive methods within the same study for direct comparison.", "followUp": "", "plainFinding": "Early fistulotomy prevented recurrence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32312918/", "sourceText": "INTRODUCTION: Perianal abscess and fistula-in-ano are common findings in infants and children. The perianal abscess is usually a manifestation of a fistula-in-ano. Experience of our center indicates general lack of knowledge of the origin of the abscess and therefore, it is usually treated by incision and drainage, which leads to repeated recurrences. AIM: We aimed to present the optimal management of fistula-in-ano and perianal abscess in order to reduce or even eliminate the risk of recurrence. MATERIAL AND METHODS: The retrospective study included 24 infants with perianal abscess treated at our center between 2013 and 2015. Patients were divided into two groups: group I (50%) was primary treated in our center, while group II had undergone prior surgical interventions in other hospitals. Fistula-in-ano was intraoperatively identified in all patients (100%) and fistulotomy was performed. RESULTS: No fecal incontinence or recurrence of perianal abscess were observed in any of our patients. In group II, the disorder was associated with severe inflammation, some patients underwent an additional surgical intervention, such as incision and drainage of an extensive buttock's abscess; patients required longer antibiotic therapy and prolonged hospitalization. CONCLUSION: Minimally invasive approach (sitz baths, antibiotic therapy, puncture or incision and drainage of the abscess) appears tempting due to its simplicity and lack of need for general anesthesia, but it is associated with a high recurrence rate. Fistulotomy and fistulectomy, which are slightly more invasive procedures, significantly reduce the recurrence rate of fistulain- ano and perianal abscess.", "provenance": [ { "field": "n", "quote": "The retrospective study included 24 infants with perianal abscess treated at our center between 2013 and 2015." }, { "field": "population", "quote": "Perianal abscess and fistula-in-ano are common findings in infants and children." }, { "field": "intervention", "quote": "Fistula-in-ano was intraoperatively identified in all patients (100%) and fistulotomy was performed." }, { "field": "comparator", "quote": "Minimally invasive approach (sitz baths, antibiotic therapy, puncture or incision and drainage of the abscess) appears tempting due to its simplicity and lack of need for general anesthesia, but it is associated with a high recurrence rate." }, { "field": "primaryOutcome", "quote": "No fecal incontinence or recurrence of perianal abscess were observed in any of our patients." }, { "field": "result", "quote": "Fistulotomy and fistulectomy, which are slightly more invasive procedures, significantly reduce the recurrence rate of fistulain- ano and perianal abscess." } ] }, { "id": "pmid:31974827", "pmid": "31974827", "doi": "10.1007/s10151-019-02144-1", "nctId": null, "pmcid": null, "title": "Evaluation and management of perianal abscess and anal fistula: SICCR position statement", "firstAuthor": "Amato", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2020, "design": "guideline", "n": null, "nField": "not-reported", "population": "people with perianal abscess or anal fistula", "intervention": "surgical treatment approaches for perianal sepsis", "comparator": "different surgical procedures compared to each other", "primaryOutcome": "recurrence and continence problems after treatment", "result": "the abstract does not report a specific quantitative result, it reviews literature to provide recommendations", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a narrative position statement summarizing literature rather than presenting new study data.", "directness": "indirect", "relevanceNote": "", "limitations": "no specific data, methods, or outcomes are reported in the abstract; it is a review-based position statement", "followUp": "", "plainFinding": "No specific prevention finding reported.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/31974827/", "sourceText": "Perianal sepsis is a common condition ranging from acute abscess to chronic anal fistula. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. Surgery is the main treatment and several procedures have been developed, but the risks of recurrence and of impairment of continence still seem to be an unresolved issue. This statement reviews the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.", "provenance": [ { "field": "population", "quote": "Perianal sepsis is a common condition ranging from acute abscess to chronic anal fistula." }, { "field": "intervention", "quote": "Surgery is the main treatment and several procedures have been developed" }, { "field": "comparator", "quote": "several procedures have been developed" }, { "field": "primaryOutcome", "quote": "the risks of recurrence and of impairment of continence still seem to be an unresolved issue" }, { "field": "result", "quote": "This statement reviews the pertinent literature and provides evidence-based recommendations to improve individualized management of patients." } ] }, { "id": "pmid:31642447", "pmid": "31642447", "doi": "10.12659/MSM.917836", "nctId": null, "pmcid": "PMC6822332", "title": "Relationship Between Body Mass Index and Recurrence/Anal Fistula Formation Following Initial Operation for Anorectal Abscess", "firstAuthor": "Lu", "multipleAuthors": true, "journal": "Med Sci Monit", "year": 2019, "design": "retrospective", "n": 790, "nField": "reported", "population": "patients who had surgery for anorectal abscess", "intervention": "higher body mass index (BMI 26.0-40.6 kg/m²)", "comparator": "lower body mass index (BMI 15.7-22.8 kg/m²)", "primaryOutcome": "recurrence of anorectal abscess or anal fistula formation after surgery", "result": "patients with higher BMI had a higher risk of recurrence than those with lower BMI", "resultDirection": "harm", "quality": "low", "qualityWhy": "this is a retrospective single-center study without randomization, so it can show a link but not prove that higher BMI causes recurrence.", "directness": "indirect", "relevanceNote": "", "limitations": "retrospective, single-hospital registry design; no mention of controlling for other confounders beyond the stated adjusted model", "followUp": "27 (range, 1-38) months", "plainFinding": "Higher BMI linked to more recurrence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/31642447/", "sourceText": "BACKGROUND The association between body mass index (BMI) and recurrence of anorectal abscess remains controversial. This study investigated the exact relationship between BMI and anorectal abscess recurrence or anal fistula formation following initial surgery. MATERIAL AND METHODS This was a retrospective registry-based study conducted at the First Affiliated Hospital of Guizhou University of Chinese Medicine. Patients treated for anorectal abscess from 01/2015 to 03/2016 were included. Clinical data and time to recurrence were recorded. The Cox regression model was used to estimate the association between BMI and recurrence. RESULTS A total of 790 patients were operated on during the study period. The average age of the participants was 38.3±11.6 years, and 83.2% were male. Median follow-up was 27 (range, 1-38) months. Compared with the low BMI (range, 15.7-22.8 kg/m²) patients, the high BMI (range, 26.0-40.6 kg/m²) patients showed higher risk of recurrence (HR=1.75, 95% CI: 1.15-2.67). In the non-adjusted model, high BMI was found to be positively correlated with recurrence (HR=1.62, 95% CI: 1.10-2.40, P=0.02), and a stronger association was found in the fully adjusted model (HR=1.75, 95% CI: 1.15-2.67, P=0.01). BMI was also used as a continuous variable for sensitivity analysis, and a similar trend was observed (P=0.01 for trend). CONCLUSIONS Elevated BMI is an independent risk factor of anorectal abscess recurrence and for increased risk of abscess recurrence or anal fistula formation.", "provenance": [ { "field": "n", "quote": "A total of 790 patients were operated on during the study period." }, { "field": "population", "quote": "Patients treated for anorectal abscess from 01/2015 to 03/2016 were included." }, { "field": "intervention", "quote": "high BMI (range, 26.0-40.6 kg/m²) patients" }, { "field": "comparator", "quote": "low BMI (range, 15.7-22.8 kg/m²) patients" }, { "field": "primaryOutcome", "quote": "anorectal abscess recurrence or anal fistula formation following initial surgery" }, { "field": "result", "quote": "high BMI (range, 26.0-40.6 kg/m²) patients showed higher risk of recurrence (HR=1.75, 95% CI: 1.15-2.67)" }, { "field": "followUp", "quote": "Median follow-up was 27 (range, 1-38) months." } ] }, { "id": "pmid:31469939", "pmid": "31469939", "doi": "10.1111/ped.13996", "nctId": null, "pmcid": null, "title": "Perianal abscess in infants: Amenable to conservative treatment in selected cases", "firstAuthor": "Samuk", "multipleAuthors": true, "journal": "Pediatr Int", "year": 2019, "design": "retrospective", "n": 19, "nField": "reported", "population": "infants under 24 months with perianal abscess", "intervention": "conservative management (antibiotics without surgery) for selected perianal abscess cases", "comparator": "surgical drainage (historical/standard approach)", "primaryOutcome": "need for surgical intervention and abscess/fistula recurrence", "result": "13 of 17 followed patients avoided surgery; one patient developed fistula-in-ano that healed on its own", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This was a small, retrospective study of only 19 infants without a comparison group, so it can't reliably show whether this approach prevents fistulas.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective design, small sample size, no control group, two patients lost to follow-up.", "followUp": "22.4 months", "plainFinding": "Conservative care often avoided surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/31469939/", "sourceText": "BACKGROUND: Perianal abscess is a common surgical condition in daily pediatric practice. Management is a subject of controversy and a variety of approaches are practiced. While the most frequent approach is drainage with/without fistulotomy, the superiority of this approach and the place of conservative approach has not been established. The aim of this study was to evaluate the outcomes of conservative approach in selected cases of perianal abscesses in infants. METHODS: Data of 19 patients aged <24 months treated conservatively for perianal abscess at a tertiary hospital in 2014-2018 were retrospectively reviewed. RESULTS: Criteria for a conservative approach were: spontaneous drainage into the anal canal (n = 8) or perianal skin (n = 4), and phlegmonous infiltrate with fluid collection detected on ultrasound (n = 7). Mean age at symptom onset was 8.4 months. Twelve patients were managed for the first time. Previous care in seven patients included 1-4 drainage procedures (n = 4), spontaneous drainage (n = 1) and antibiotics (n = 2). Five patients were on oral antibiotics at presentation. After diagnosis, 18 patients received i.v. antibiotics and one, oral antibiotics. Three patients (15.7%) ultimately required surgical drainage; two were lost to follow up. During follow up (mean, 22.4 months) four patients (28.5%) had a single recurrent episode; abscess in three (managed conservatively in two and surgically in one) and fistula-in-ano in one patient that healed spontaneously. Thus, surgical intervention was prevented in 13/17 patients (76.4%) available for follow up. CONCLUSIONS: Perianal abscess in infants is amenable to conservative management in selected cases. Avoiding surgical intervention is advantageous, especially given the high recurrence rate.", "provenance": [ { "field": "n", "quote": "Data of 19 patients aged <24 months treated conservatively for perianal abscess" }, { "field": "population", "quote": "Data of 19 patients aged <24 months treated conservatively for perianal abscess at a tertiary hospital" }, { "field": "intervention", "quote": "The aim of this study was to evaluate the outcomes of conservative approach in selected cases of perianal abscesses in infants." }, { "field": "comparator", "quote": "the most frequent approach is drainage with/without fistulotomy" }, { "field": "primaryOutcome", "quote": "Thus, surgical intervention was prevented in 13/17 patients (76.4%) available for follow up." }, { "field": "result", "quote": "four patients (28.5%) had a single recurrent episode; abscess in three (managed conservatively in two and surgically in one) and fistula-in-ano in one patient that healed spontaneously" }, { "field": "followUp", "quote": "During follow up (mean, 22.4 months)" } ] }, { "id": "pmid:31054551", "pmid": "31054551", "doi": "10.3760/cma.j.issn.1671-0274.2019.04.009", "nctId": null, "pmcid": null, "title": "[Application of closed negative pressure irrigation and suction device in the treatment of high perianal abscess]", "firstAuthor": "Chen", "multipleAuthors": true, "journal": "Zhonghua Wei Chang Wai Ke Za Zhi", "year": 2019, "design": "rct", "n": 80, "nField": "reported", "population": "adults with a first-time high perianal abscess", "intervention": "closed negative pressure irrigation and suction device after abscess drainage", "comparator": "conventional incision and drainage with gauze dressing changes", "primaryOutcome": "rate of anal fistula formation and abscess recurrence after surgery", "result": "lower rate of anal fistula formation and abscess recurrence, higher one-time cure rate, less pain and faster healing with negative pressure device", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "it was a randomized trial but came from a single center with a modest number of patients and excluded complex cases like diabetes or Crohn's disease.", "directness": "direct", "relevanceNote": "", "limitations": "single-center study, excluded patients with diabetes, immunosuppression, Crohn's disease, or recurrent abscess, which limits how broadly results apply", "followUp": "12 to 36 (24±5) months", "plainFinding": "Fewer fistulas with suction device.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/31054551/", "sourceText": "Objective: To explore the efficacy of closed negative pressure irrigation and suction device (Patent number: Z200780013509.8) in the treatment of high perianal abscess. Methods: From January 2015 to December 2016, ≥18-year-old patients with primary high perianal abscess who were treated at our department were prospectively enrolled. Exclusion criteria: (1) recurrent perianal abscess; (2) complicated with anal fistula formation; (3) preoperative, intraoperative or postoperative physical therapy, and curettage treatment, negative pressure irrigation; (4) Crohn's disease-related perianal abscess; (5) with immunosuppressive status, such as transplant recipients; (6) co-existence of malignant tumors, such as leukemia; (7) with diabetes; (8) those who could not receive long-term follow-up and were not suitable to participate in this study. According to the random number table method, the patients were randomly divided into negative pressure irrigation and suction group and routine drainage group. All patients were clearly diagnosed and the location and size of the perianal abscess were marked before surgery. These two groups were treated as follows: (1) Negative pressure irrigation and suction group: the skin was incised at a diameter of 1-2 cm at the site where the abscess fluctuated most obviously. After the abscess was removed, a closed negative pressure irrigation and suction device was installed and the pressure of -200 to -100 mmHg (1 mmHg=0.133 kPa) was maintained to keep the abscess cavity collapsed. Generally, the irrigation was stopped 5 days later or when the drainage was clear. The closed vacuum suction was maintained for 2 additional days, before the wound was sutured. (2) Conventional drainage group: conventional incision and drainage was carried out. The skin was cut at a diameter of 8 to 10 cm at the site of abscess with most obvious fluctuation. After the abscess was removed, normal saline gauze was used for dressing. Dressing was changed regularly until the wound healed. The efficacy, operative time, intraoperative bleeding, incision length, frequency of dressing change, pain index (visual analogue score, VAS score), postoperative healing time, complications, recurrence rate of perianal abscess, anal fistula formation rate were observed. The t test and χ2 test were used for comparison between the 2 groups. Results: There were both 40 patients in the negative pressure irrigation and suction group and the conventional drainage group. There were 28 males and 12 females in negative pressure irrigation and suction group with a mean age of (38.3±12.0) years and mean disease course of (6.6±2.1) days. The abscess in pelvic-rectal space accounted for 50.0% (20/40) and the mean diameter of abscess was (8.0±3.7) cm. There were 26 males and 14 females in the conventional drainage group with a mean age of (37.1±11.8) years and mean disease course of (6.4±2.5) days. The abscess in pelvic-rectal space accounted for 55.0% (22/40) and the diameter of abscess was (8.2±3.5) cm. The differences in baseline data between two groups were not statistically significant (all P>0.05). Both groups successfully completed the operation. There was no significant difference in operative time between two groups (P>0.05). As compared to conventional drainage group, intraoperative blood loss in negative pressure irrigation and suction group was less [(12.1±5.5) ml vs. (18.3±4.4) ml, t=5.606, P<0.001], incision length was shorter [(2.3±0.8) cm vs. (7.6±1.7) cm, t=17.741, P<0.001], postoperative VAS pain scores at 1-, 3-, 7-, and 14-day after operation were lower [3.7±1.4 vs. 7.6±1.8, t=10.816, P<0.001; 3.0±1.3 vs. 6.8±1.6, t=11.657, P<0.001; 2.7±0.9 vs. 5.1±1.1, t=10.679, P<0.001; 1.2±0.3 vs. 1.6±0.4, t=5.060, P=0.019], the dressing change within 7 days after operation was less (3.5±1.2 vs. 12.6±2.7, t=19.478, P<0.001), postoperative healing time was shorter [(10.4±3.0) d vs. (13.5±3.8) d, t=4.049, P<0.001] and postoperative complication rate was lower [17.5% (7/40) vs. 2.5% (1/40), χ2=5.000, P=0.025]. During follow-up of 12 to 36 (24±5) months, the recurrence rate of perianal abscess within 1 year after operation and anal fistula formation rate in negative pressure irrigation and suction group were lower than those in conventional drainage group [5.0% (2/40) vs. 20.0% (8/40), χ2=4.114, P=0.042 and 2.5% (1/40) vs. 17.5% (7/40), χ2=5.000, P=0.025, respectirely]. The one-time cure rate of negative pressure irrigation and suction group and conventional drainage group was 92.5% (37/40) and 62.5%(25/40), respectirely (χ2=10.323, P=0.001). Conclusions: The application of the negative pressure irrigation and suction device in the treatment of high perianal abscess can improve the efficiency of one-time cure, reduce postoperative pain, accelerate healing time, decrease the morbidity of postoperative complication and the rates of abscess recurrence and anal fistula formation, indicating an improvement of the treatment.", "provenance": [ { "field": "n", "quote": "There were both 40 patients in the negative pressure irrigation and suction group and the conventional drainage group." }, { "field": "population", "quote": "≥18-year-old patients with primary high perianal abscess who were treated at our department were prospectively enrolled" }, { "field": "intervention", "quote": "a closed negative pressure irrigation and suction device was installed and the pressure of -200 to -100 mmHg (1 mmHg=0.133 kPa) was maintained to keep the abscess cavity collapsed" }, { "field": "comparator", "quote": "Conventional drainage group: conventional incision and drainage was carried out." }, { "field": "primaryOutcome", "quote": "recurrence rate of perianal abscess, anal fistula formation rate were observed" }, { "field": "result", "quote": "the recurrence rate of perianal abscess within 1 year after operation and anal fistula formation rate in negative pressure irrigation and suction group were lower than those in conventional drainage group [5.0% (2/40) vs. 20.0% (8/40), χ2=4.114, P=0.042 and 2.5% (1/40) vs. 17.5% (7/40), χ2=5.000, P=0.025, respectirely]" } ] }, { "id": "pmid:30773213", "pmid": "30773213", "doi": "10.1016/j.amjsurg.2019.01.015", "nctId": null, "pmcid": null, "title": "Antibiotic use in prevention of anal fistulas following incision and drainage of anorectal abscesses: A systematic review and meta-analysis", "firstAuthor": "Mocanu", "multipleAuthors": true, "journal": "Am J Surg", "year": 2019, "design": "meta-analysis", "n": 817, "nField": "reported", "population": "patients who had surgical drainage of an anorectal abscess", "intervention": "antibiotics after drainage", "comparator": "no antibiotics after drainage", "primaryOutcome": "developing an anal fistula afterward", "result": "Lower rate of fistula formation with antibiotics (16% vs 24%), statistically significant on pooled analysis", "resultDirection": "benefit", "quality": "low", "qualityWhy": "Based on pooling only three studies with low-quality evidence, as stated by the authors themselves.", "directness": "direct", "relevanceNote": "", "limitations": "Quality of evidence is low; only three studies contributed to the pooled odds ratio; antibiotic regimens varied; authors call for further randomized trials.", "followUp": "one to 30 months", "plainFinding": "Antibiotics lowered fistula risk.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30773213/", "sourceText": "BACKGROUND: Treatment of anorectal abscesses continues to revolve around early surgical drainage and control of perianal sepsis. Yet even with prompt drainage, abscess recurrence and postoperative fistula formation rates are as high as 40% within 12 months. These complications are thought to be associated with inadequate drainage, elevated bacterial load, or a noncryptoglandular etiology of disease. Postoperative antibiotics have been used to account for these limitations, but their use is controversial and only weakly supported by current guidelines due to low-quality evidences. The aim of the present study was to perform a systematic review and meta-analysis of the current literature to determine the role of antibiotics in prevention of anal fistula following incision and drainage of anorectal abscesses. METHODS: Literature search was conducted using Medline, EMBASE, Scopus, the Cochrane Library, and Web of Science databases from 1946 to April 2018. Search terms were \"perianal OR anal OR fistula-in-ano OR ischiorectal OR anorectal AND abscess AND antibiotics\" and was limited to human studies in the English language. Literature review and data extraction were completed using PRISMA guidelines. A total of six studies with 817 patients were included for systematic review. The weighted mean age was 37.8 years, 20.4% of patients were female, and the follow up ranged from one to 30 months. Antibiotic courses varied by study, and duration ranged from five to 10 days. Of included patients, 358 (43.8%) underwent management without antibiotics while 459 (56.2%) patients were treated with antibiotics. Fistula rate in subjects receiving antibiotics was 16% versus 24% in those not receiving postoperative antibiotics. Meta-analysis revealed a statistically significant protective effect for antibiotic treatment (3 studies, OR 0.64; CI 0.43-0.96; P = 0.03). CONCLUSIONS: Antibiotic therapy following incision and drainage of anorectal abscesses is associated with a 36% lower odds of fistula formation. An empiric 5-10-day course of antibiotics following operative drainage may avoid the morbidity of fistula formation in otherwise healthy patients, although quality of evidence is low. Further randomized trials are needed to fully clarify the role, duration, and type of antibiotics best suited for postoperative prevention of fistula following drainage of anorectal abscesses.", "provenance": [ { "field": "n", "quote": "A total of six studies with 817 patients were included for systematic review." }, { "field": "population", "quote": "following incision and drainage of anorectal abscesses" }, { "field": "intervention", "quote": "459 (56.2%) patients were treated with antibiotics" }, { "field": "comparator", "quote": "358 (43.8%) underwent management without antibiotics" }, { "field": "primaryOutcome", "quote": "to determine the role of antibiotics in prevention of anal fistula following incision and drainage of anorectal abscesses" }, { "field": "result", "quote": "Fistula rate in subjects receiving antibiotics was 16% versus 24% in those not receiving postoperative antibiotics. Meta-analysis revealed a statistically significant protective effect for antibiotic treatment (3 studies, OR 0.64; CI 0.43-0.96; P = 0.03)." }, { "field": "followUp", "quote": "the follow up ranged from one to 30 months" }, { "field": "qualityWhy", "quote": "although quality of evidence is low" } ] }, { "id": "pmid:28822559", "pmid": "28822559", "doi": "10.1016/j.surg.2017.07.001", "nctId": null, "pmcid": null, "title": "Antibiotic therapy for prevention of fistula in-ano after incision and drainage of simple perianal abscess: A randomized single blind clinical trial", "firstAuthor": "Ghahramani", "multipleAuthors": true, "journal": "Surgery", "year": 2017, "design": "rct", "n": 299, "nField": "reported", "population": "patients referring for incision and drainage of perianal abscess at Shahid Faghihi Hospital, Shiraz, Iran", "intervention": "7 days of antibiotics (metronidazole and ciprofloxacin) after surgery plus standard care", "comparator": "standard care only, no antibiotics", "primaryOutcome": "development of anal fistula within 3 months", "result": "significantly fewer patients who took antibiotics developed an anal fistula", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "it was a randomized trial but only single-blind and from one hospital, so bias and generalizability are limited", "directness": "direct", "relevanceNote": "", "limitations": "single blind design and seven patients lost to follow-up", "followUp": "3 months", "plainFinding": "Antibiotics after drainage prevented fistulas.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28822559/", "sourceText": "BACKGROUND: Much controversy exists regarding the role of antibiotics in the development of fistula in-ano after incision and drainage. We evaluated the role of postoperative antibiotics in the prevention of fistula in-ano after incision and drainage of perianal abscess. METHODS: In a randomized single blind clinical trial study, 307 patients were randomly selected from those referring for incision and drainage of perianal abscess at Shahid Faghihi Hospital, Shiraz, Iran, during September 2013 to September 2014. Patients were allocated randomly either to receive 7 days of oral metronidazole and ciprofloxacin in addition to their standard care or to only receive standard care without any antibiotics after they were discharged from the hospital. Patients were followed for 3 months and final results were evaluated. The study was registered at the clinical trial registry (www.irct.ir; Irct201311049936n7). RESULTS: Seven patients were lost to follow-up. Those who used prophylactic antibiotics (n = 155) had significantly lower rates of fistula formation compared with those who did not use any medication (n = 144; P < .001). Men had higher rates of fistula formation (P = .002). Patients who used more cigarettes had higher rates of fistula development (P = .001). In the univariate analysis, only postoperative antibiotic use showed a protective role against fistula formation (odds ratio = 0.426; confidence interval, 0.206-0.881). In the regression analysis postoperative antibiotic use remained protective against fistula development (odds ratio = 0.371; confidence interval, 0.196-0.703), furthermore male sex presented as a risk factor for developing fistula in-ano (odds ratio = 3.11; confidence interval, 1.31-7.38). CONCLUSION: Postoperative prophylactic antibiotic therapy including ciprofloxacin and metronidazole play an important role in preventing fistula in-ano formation. Considering the complications of fistula in-ano formation and the minor side effects of antibiotic therapy, based on our results, a 7-10 course of postoperative antibiotics is advised after incision and drainage of perianal abscess.", "provenance": [ { "field": "n", "quote": "Those who used prophylactic antibiotics (n = 155) had significantly lower rates of fistula formation compared with those who did not use any medication (n = 144" }, { "field": "population", "quote": "307 patients were randomly selected from those referring for incision and drainage of perianal abscess at Shahid Faghihi Hospital, Shiraz, Iran" }, { "field": "intervention", "quote": "receive 7 days of oral metronidazole and ciprofloxacin in addition to their standard care" }, { "field": "comparator", "quote": "only receive standard care without any antibiotics after they were discharged from the hospital" }, { "field": "primaryOutcome", "quote": "We evaluated the role of postoperative antibiotics in the prevention of fistula in-ano after incision and drainage of perianal abscess." }, { "field": "result", "quote": "Those who used prophylactic antibiotics (n = 155) had significantly lower rates of fistula formation compared with those who did not use any medication (n = 144; P < .001)." } ] }, { "id": "pmid:28564707", "pmid": "28564707", "doi": "10.1055/s-0037-1603092", "nctId": null, "pmcid": null, "title": "Treatment of First-Time Perianal Abscess in Childhood, Balance Recurrence and Fistula Formation Rate with Medical Intervention", "firstAuthor": "Gong", "multipleAuthors": true, "journal": "Eur J Pediatr Surg", "year": 2018, "design": "retrospective", "n": 697, "nField": "reported", "population": "children with their first perianal abscess", "intervention": "conservative (non-surgical) treatment of the abscess", "comparator": "incision and drainage surgery", "primaryOutcome": "recurrence and/or fistula formation rate", "result": "conservative treatment had a lower rate of recurrence/fistula (12.7%) than incision and drainage (24.6%)", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This is a retrospective study without randomization, so treatment choice could be biased by abscess severity.", "directness": "direct", "relevanceNote": "", "limitations": "Retrospective design; not randomized; treatment assignment not controlled", "followUp": "395 days", "plainFinding": "Less fistula with conservative treatment.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28564707/", "sourceText": "PURPOSE: Because of differences in therapy for first-time perianal abscess, a wide range of recurrences and/or development of fistula-in-ano (RF) rates have been reported. The indication for determining when surgical intervention is needed remains obscure and controversial. This retrospective study sought to compare outcomes of conservative treatment with those after incision and drainage (ID) to determine the optimal time for surgical intervention. METHODS: A total of 697 patients with first-time perianal abscess were included in this study. The median patient age at the time of onset was 129 days (range: 5-5,110 days). The median follow-up period was 395 days (range: 120-760 days). RESULTS: Of the 697 patients with first-time perianal abscess, 355 (50.9%) patients who received conservative treatment had 12.7% (45/355) RF rate, which is less than that of abscesses treated with ID (24.6%, 72/297; p < 0.001). The median course was 23 (2,466) days, which did not differ significantly from that of abscesses with ID (18 [3,510] days) (p = 0.609). Forty-six (6.6%) patients with abscesses that perforated spontaneously had 10.9% (5/46) RF rate, which was less than that of abscesses with ID (p = 0.019), and the median course was 9 (3,316) days, which was shorter than that of abscesses with ID (p = 0.04). CONCLUSION: Conservative treatment is a safe and effective technique for most first-time perianal abscesses with less recurrence and a lower fistula formation rate. Incision must be performed when an abscess is likely to spread or shows no sign of spontaneous perforation.", "provenance": [ { "field": "n", "quote": "A total of 697 patients with first-time perianal abscess were included in this study." }, { "field": "population", "quote": "patients with first-time perianal abscess" }, { "field": "intervention", "quote": "355 (50.9%) patients who received conservative treatment" }, { "field": "comparator", "quote": "abscesses treated with ID (24.6%, 72/297; p < 0.001)" }, { "field": "primaryOutcome", "quote": "a wide range of recurrences and/or development of fistula-in-ano (RF) rates have been reported" }, { "field": "result", "quote": "355 (50.9%) patients who received conservative treatment had 12.7% (45/355) RF rate, which is less than that of abscesses treated with ID (24.6%, 72/297; p < 0.001)." }, { "field": "followUp", "quote": "The median follow-up period was 395 days (range: 120-760 days)." } ] }, { "id": "pmid:27459618", "pmid": "27459618", "doi": "10.17116/terarkh201688772-77", "nctId": null, "pmcid": null, "title": "[Perianal infection in patients with hemoblastosis: Risk factors and possibilities of prevention]", "firstAuthor": "Shtyrkova", "multipleAuthors": true, "journal": "Ter Arkh", "year": 2016, "design": "prospective-cohort", "n": 72, "nField": "reported", "population": "patients with hemoblastosis", "intervention": "surgical treatment for anal fissures and fistulas performed between chemotherapy cycles", "comparator": "patients treated medically (without surgery) for anal canal disease", "primaryOutcome": "risk of complications and recurrence of perianal infection during continued chemotherapy", "result": "surgically treated patients had a 5 times lower risk of perianal complications than medically treated patients", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a small, non-randomized prospective study in a very specific cancer population, so the findings may not generalize.", "directness": "indirect", "relevanceNote": "", "limitations": "Not randomized; small subgroup (29 patients) underwent surgery; population limited to hematologic cancer patients during chemotherapy.", "followUp": "", "plainFinding": "Surgery lowered infection recurrence risk.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/27459618/", "sourceText": "AIM: to identify poor prognostic factors for perianal infection (PI) in patients with hemoblastosis and to define an effective tactic for preventive and therapeutic measures. SUBJECTS AND METHODS: The prospective study enrolled 72 patients (37 men and 35 women; mean age, 47 years) with hemoblastosis that was complicated by the development of one of the following forms of PI: abscess, infiltrate, multiple ulcers. Different clinical and laboratory characteristics of the patients were examined to identify risk factors for PI. The species-specific concordance of microorganisms isolated from the anus and blood in the development of PI was assessed to record the latter as a source of sepsis. Treatment policy was defined according to the clinical form of PI. RESULTS: Acute myeloid leukemias and lymphomas were the most common background diseases in 30 (41.7%) and 22 (30.6%) patients, respectively. During induction chemotherapy cycles, perianal tissue infection occurred twice more frequently (66%) than totally at the onset of hemoblastosis (13%) and after achievement of remission (during consolidation and maintenance therapy) (21%; Fisher's exact test; p=0.01). PI in agranulocytosis was more than twice as common as in its absence: 69.4% vs 30.6% (p=0.01) and was responsible for sepsis in 9 (18%) of 50 patients. The main source of perianal tissue infection in patients with granulocytopenia was anal fissures and fistulas and ulcers of the anal canal: 44 (88%) cases of the 50 cases. In PI as an abscess, the average white blood cell count was 5 times higher (p=0.01) than that in PI as an infiltrate (or multiple ulcers): 6.6·109/l and 1.2·109 g/l. Abscess formation was observed in 16 (22.2%) patients and an indication for surgical drain. The inflammatory infiltrate was found to develop in 48 (66.7%) patients; multiple ulcers were seen in 8 (11.1%); in this group, parenteral antimicrobial therapy proved to be effective in 36 (78%) patients. 29 patients were operated on for anal fissures and fistulas at intercycle intervals. After continuing CT, PI recurrences were observed in 4 (9.1%) patients. In the operated versus medically treated patients, the risk of complications associated with abnormalities in the perianal area during continued CT was 5 times statistically significantly lower (odds ratio=0.2; 95% confidence interval 0.1 to 0.5; p=0.04; Cochran-Mantel test). CONCLUSION: Induction CT cycles, the status of granulocytopenia, and the presence of infection sources in the anal canal as an anal fissure, skin ulcerations, or a fistula should be considered as independent statistically significant prognostic risk factors for PI. The number of granulocytes determines the form of inflammation, the course of infection, and the chance of developing sepsis. The effective prevention encompassing surgical treatment for anal canal diseases reduces the risk of septic complications and the number of paraproctitis recurrences, contributing to the implementation of a planned CT program in patients with hemoblastosis.", "provenance": [ { "field": "n", "quote": "The prospective study enrolled 72 patients (37 men and 35 women; mean age, 47 years) with hemoblastosis" }, { "field": "population", "quote": "with hemoblastosis" }, { "field": "intervention", "quote": "29 patients were operated on for anal fissures and fistulas at intercycle intervals" }, { "field": "comparator", "quote": "In the operated versus medically treated patients, the risk of complications associated with abnormalities in the perianal area during continued CT was 5 times statistically significantly lower" }, { "field": "primaryOutcome", "quote": "the risk of complications associated with abnormalities in the perianal area during continued CT" }, { "field": "result", "quote": "the risk of complications associated with abnormalities in the perianal area during continued CT was 5 times statistically significantly lower (odds ratio=0.2; 95% confidence interval 0.1 to 0.5; p=0.04; Cochran-Mantel test)" } ] }, { "id": "pmid:27226422", "pmid": "27226422", "doi": "10.1111/ans.13630", "nctId": null, "pmcid": null, "title": "Bacteriological study in perianal abscess is not useful and not cost-effective", "firstAuthor": "Xu", "multipleAuthors": true, "journal": "ANZ J Surg", "year": 2016, "design": "retrospective", "n": 164, "nField": "reported", "population": "patients who had surgery to drain a perianal abscess", "intervention": "bacterial culture testing of pus from the abscess", "comparator": "no culture testing / comparing gut organisms vs skin organisms vs no growth", "primaryOutcome": "development of anal fistula or recurrence of abscess", "result": "presence of gut organisms was not significantly linked to developing a fistula or abscess recurrence", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "This was a retrospective study without randomization, so it can show an association but not prove prevention.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective design; abstract does not describe how confounders were handled.", "followUp": "1450 (14-2391) days", "plainFinding": "Culture testing didn't predict fistula risk.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/27226422/", "sourceText": "BACKGROUND: The detection of gut organisms in perianal abscesses has been postulated to suggest an underlying communication with the anal canal. However, recent studies appear to contradict this observation. The aim of this study is to determine the value of bacteriological studies in perianal abscesses. METHODS: A retrospective study of all patients who have had a surgical drainage of their perianal abscesses with concomitant microbiological examination from January 2010 to December 2012 was performed. Patients with known underlying anal fistula, Crohn's disease or previous perianal operations were excluded. RESULTS: A total of 164 patients, median age of 42.0 years (range 8-87) comprising of 78.7% males formed the study group. Gut organisms were cultured in 143 (87.2%) samples while 12 (7.3%) demonstrated skin organisms and nine did not yield any bacterial growth (5.5%). Twenty-nine (17.7%) patients developed anal fistula and 34 (20.7%) patients had a recurrence of the perianal abscess. The median follow-up period was 1450 (14-2391) days. There was no significant association between the presence of gut organism and development of fistulas (odds ratio = 0.48; 95% confidence interval = 0.17-1.37) or recurrence of perianal abscess (odds ratio = 1.66; 95% confidence interval = 0.46-6.01). CONCLUSION: Bacteriological culture in perianal abscess is not useful for predicting the development of anal fistula or abscess recurrence. Hence, there is no need to perform this investigation on a routine basis.", "provenance": [ { "field": "n", "quote": "A total of 164 patients" }, { "field": "population", "quote": "patients who have had a surgical drainage of their perianal abscesses with concomitant microbiological examination" }, { "field": "intervention", "quote": "The detection of gut organisms in perianal abscesses has been postulated to suggest an underlying communication with the anal canal" }, { "field": "comparator", "quote": "Gut organisms were cultured in 143 (87.2%) samples while 12 (7.3%) demonstrated skin organisms and nine did not yield any bacterial growth (5.5%)" }, { "field": "primaryOutcome", "quote": "Twenty-nine (17.7%) patients developed anal fistula and 34 (20.7%) patients had a recurrence of the perianal abscess" }, { "field": "result", "quote": "There was no significant association between the presence of gut organism and development of fistulas (odds ratio = 0.48; 95% confidence interval = 0.17-1.37) or recurrence of perianal abscess (odds ratio = 1.66; 95% confidence interval = 0.46-6.01)" }, { "field": "followUp", "quote": "The median follow-up period was 1450 (14-2391) days" } ] }, { "id": "pmid:27061287", "pmid": "27061287", "doi": "10.1002/bjs.10154", "nctId": null, "pmcid": null, "title": "Multicentre observational study of outcomes after drainage of acute perianal abscess", "firstAuthor": "Pearce", "multipleAuthors": true, "journal": "Br J Surg", "year": 2016, "design": "prospective-cohort", "n": 141, "nField": "reported", "population": "adults with an acute perianal abscess treated with surgical drainage", "intervention": "standard postoperative wound packing (dressing changes) after abscess drainage", "comparator": "no control group; outcomes of usual care were observed without comparison", "primaryOutcome": "development of a fistula in ano and wound healing after abscess drainage", "result": "about a quarter of patients developed a fistula within 6 months, and wound packing caused repeated pain without clear benefit", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "this was an observational study with no comparison group, so it cannot show whether packing or any other step actually changes the chance of a fistula forming.", "directness": "indirect", "relevanceNote": "", "limitations": "no control group for comparison, observational design, and the abstract notes limited evidence for the value of wound packing itself", "followUp": "6 months", "plainFinding": "Packing didn't prevent fistula, just pain.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/27061287/", "sourceText": "INTRODUCTION: Management of perianal abscesses has remained largely unchanged for over 50 years. The evidence for postoperative wound packing is limited and may expose patients to painful procedures with no clinical benefit and at considerable increased cost. METHODS: Patients were recruited in 15 UK centres between December 2013 and October 2014. Outcome measures included number of dressing (pack) changes, healing, recurrence, return to work/normal function, postoperative fistula in ano and health utility scores (EQ-5D™). Pain was measured before, during and after dressing change on a visual analogue scale. RESULTS: Some 141 patients were recruited (median age 39 (range 18-86) years). The mean number of dressing changes in the first 3 weeks was 13 (range 0-21), equating to an annual cost to the National Health Service of €6 453 360 in England alone per annum. Some 43·8 per cent of wounds were healed by 8 weeks after surgery and 86 per cent of patients had returned to normal function. Some 7·6 per cent of abscesses had recurred and 26·7 per cent of patients developed a fistula in ano by 6 months following surgery. Patients reported a twofold to threefold increase in pain scores during and after dressing changes. CONCLUSION: Recurrent abscess is rare and fistula occurs in one-quarter of the patients. Packing is painful and costly.", "provenance": [ { "field": "population", "quote": "Patients were recruited in 15 UK centres between December 2013 and October 2014." }, { "field": "intervention", "quote": "The evidence for postoperative wound packing is limited and may expose patients to painful procedures with no clinical benefit and at considerable increased cost." }, { "field": "comparator", "quote": "The evidence for postoperative wound packing is limited" }, { "field": "primaryOutcome", "quote": "Outcome measures included number of dressing (pack) changes, healing, recurrence, return to work/normal function, postoperative fistula in ano and health utility scores (EQ-5D™)." }, { "field": "result", "quote": "26·7 per cent of patients developed a fistula in ano by 6 months following surgery." }, { "field": "result", "quote": "Patients reported a twofold to threefold increase in pain scores during and after dressing changes." }, { "field": "n", "quote": "Some 141 patients were recruited (median age 39 (range 18-86) years)." }, { "field": "followUp", "quote": "developed a fistula in ano by 6 months following surgery" } ] }, { "id": "pmid:25693779", "pmid": "25693779", "doi": "10.1007/s00104-014-2850-7", "nctId": null, "pmcid": null, "title": "[Special surgical complications in chronic inflammatory bowel diseases]", "firstAuthor": "Kroesen", "multipleAuthors": false, "journal": "Chirurg", "year": 2015, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with chronic inflammatory bowel disease having colorectal or anorectal surgery", "intervention": "omentoplasty with fixation inside the pelvis, and other surgical techniques like gracilis muscle transposition or seton drainage", "comparator": "not reported", "primaryOutcome": "prevention or treatment of pelvic sepsis and anal fistula complications", "result": "pelvic sepsis can be prevented by omentoplasty with pelvic fixation; other techniques help manage persisting sepsis and fistula recurrence", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a narrative review describing surgical techniques without study data, numbers, or comparison groups to support effectiveness claims", "directness": "direct", "relevanceNote": "", "limitations": "no study design details, no patient numbers, no comparator group, and no statistical results are given for the specific claim about preventing fistula or sepsis", "followUp": "", "plainFinding": "Fat-pad surgery may prevent pelvic infection.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25693779/", "sourceText": "After colorectal and anorectal interventions for chronic inflammatory bowel diseases, specific complications can occur.In Crohn's disease these complications mainly occur after proctocolectomy. Pelvic sepsis can be prevented by omentoplasty with fixation inside the pelvis. A persisting sepsis of the sacral cavity can be treated primarily by dissection of the anal sphincter which ensures better drainage. In cases of chronic sacral sepsis, transposition of the gracilis muscle is a further effective option. Early recurrence of a transsphincteric anal fistula should be treated by reinsertion of a silicon seton drainage.Complications after restorative proctocolectomy are frequent and manifold (35%). The main acute complications are anastomotic leakage and pelvic sepsis. Therapy consists of transperineal drainage of the abscess with simultaneous transanal drainage. Late complications due to technical and septic reasons are still a relevant problem even 36 years after introduction of this operative technique. A consistent approach with detailed diagnostic and surgical therapy results in a 75% rescue rate of ileoanal pouches.", "provenance": [ { "field": "population", "quote": "After colorectal and anorectal interventions for chronic inflammatory bowel diseases, specific complications can occur." }, { "field": "intervention", "quote": "Pelvic sepsis can be prevented by omentoplasty with fixation inside the pelvis." }, { "field": "primaryOutcome", "quote": "Pelvic sepsis can be prevented by omentoplasty with fixation inside the pelvis." }, { "field": "result", "quote": "Pelvic sepsis can be prevented by omentoplasty with fixation inside the pelvis." }, { "field": "comparator", "quote": "A persisting sepsis of the sacral cavity can be treated primarily by dissection of the anal sphincter which ensures better drainage." } ] }, { "id": "pmid:25339133", "pmid": "25339133", "doi": "10.1007/s00384-014-2028-2", "nctId": null, "pmcid": null, "title": "Management of cryptoglandular supralevator abscesses in the magnetic resonance imaging era: a case series", "firstAuthor": "Garcia-Granero", "multipleAuthors": true, "journal": "Int J Colorectal Dis", "year": 2014, "design": "case-series", "n": 13, "nField": "reported", "population": "patients with abscess from anal gland infection located above the pelvic floor muscles", "intervention": "MRI-guided drainage followed by subsequent surgical treatment of the fistula", "comparator": "no subsequent treatment of the fistula", "primaryOutcome": "recurrence of anal infection (fistula) over long-term follow-up", "result": "only patients whose fistula was not treated after drainage had a recurrence of anal infection", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a small retrospective case series of only 13 patients without a control group, so it cannot reliably prove cause and effect.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective design, small sample size, no comparison group, single center.", "followUp": "median 61 months", "plainFinding": "Treating fistula after drainage prevented recurrence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25339133/", "sourceText": "AIM: The aim of this study is to describe the diagnostic performance of magnetic resonance imaging in the management of supralevator abscess, regarding its origin, location, drainage route, subsequent treatment of the fistula, and long-term results. METHODS: A retrospective case series including thirteen consecutive patients with cryptoglandular supralevator abscess treated between 2001 and 2011 at a colorectal unit of a tertiary referral center. A magnetic resonance imaging was performed in all patients before surgical drainage, and its usefulness in assessing supralevator abscess origin was analyzed. Short- and long-term results after drainage were also evaluated. RESULTS: The final diagnosis of supralevator abscess and the location described in the magnetic resonance were confirmed intraoperatively in all patients. An ischiorectal origin was identified in nine patients, and perineal translevator drainage was performed placing a mushroom catheter through the ischiorectal or the postanal space. Four patients underwent secondary treatment of anal fistula: two rectal advancement flap and two non-cutting seton. In the other four patients, an intersphincteric origin was identified and transanal surgical drainage was performed placing a long-term mushroom catheter. Several weeks later, transanal unroofing of the residual cavity was performed and the fistula lay open to the anorectal lumen. In the long-term follow-up (median 61 months), only patients with supralevator abscess of ischiorectal origin in whom fistula was not subsequently treated presented a recurrence of the anal sepsis. CONCLUSIONS: Magnetic resonance imaging seems essential to clarify the location of supralevator abscess, its origin, and choice of the right drainage route. Subsequent treatment of the fistula is necessary to avoid recurrence.", "provenance": [ { "field": "n", "quote": "A retrospective case series including thirteen consecutive patients with cryptoglandular supralevator abscess treated between 2001 and 2011" }, { "field": "population", "quote": "thirteen consecutive patients with cryptoglandular supralevator abscess" }, { "field": "intervention", "quote": "Subsequent treatment of the fistula is necessary to avoid recurrence." }, { "field": "comparator", "quote": "only patients with supralevator abscess of ischiorectal origin in whom fistula was not subsequently treated presented a recurrence of the anal sepsis" }, { "field": "primaryOutcome", "quote": "long-term results after drainage were also evaluated" }, { "field": "result", "quote": "only patients with supralevator abscess of ischiorectal origin in whom fistula was not subsequently treated presented a recurrence of the anal sepsis" } ] }, { "id": "pmid:24497752", "pmid": "24497752", "doi": "10.4103/1117-6806.119237", "nctId": null, "pmcid": "PMC3899549", "title": "Fistula-in-Ano Complicated by Fournier's Gangrene Our Experience in North-Eastern Region of Nigeria", "firstAuthor": "Bakari", "multipleAuthors": true, "journal": "Niger J Surg", "year": 2013, "design": "case-series", "n": 10, "nField": "reported", "population": "men with anal fistula complicated by a severe genital infection (Fournier's gangrene)", "intervention": "early antibiotics and surgical treatment (fistulotomy, seton placement, or flap surgery) for perianal abscess/fistula", "comparator": "delayed or inadequate drainage of the abscess", "primaryOutcome": "development of Fournier's gangrene as a complication of fistula-in-ano", "result": "early antibiotics and primary surgery were associated with prevention of the gangrene complication, while inadequate or delayed drainage was linked to its development", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a small retrospective case series of only 10 patients with no comparison group, so it cannot reliably show what prevents anything.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective case review of a small number of patients, no control group, and it studies prevention of a complication (Fournier's gangrene) arising from existing fistula-in-ano rather than prevention of fistula formation itself.", "followUp": "", "plainFinding": "Early treatment may prevent severe infection complication.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24497752/", "sourceText": "BACKGROUND: Fistula-in-ano when complicated by Fournier's gangrene is an unusual finding and always carries high morbidity. This study details our experience in managing 10 cases. METHODS OF STUDY: Case files of all patients managed in University of Maiduguri Teaching Hospital and Federal Medical Center of Yola and Gombe from January, 2007 to December, 2011 were retrieved from Medical Record Departments and other Hospital Records. These were analyzed for demographic, clinical and pathological variables, the type of treatment and follow-up. RESULTS: A total of 10 men with a mean age of 50.5 years (35-60) were managed in the period of study. Nearly, 50% of the patients were farmers, 30% businessmen and 20% were civil servant. 7 (70%) of these patients presented with Fournier's gangrene within 4 weeks of development of fistula-in-ano and the rest within 8 weeks. 4 (40%) of these patients had inadequate drainage of their perianal abscess and 2 (20%) had incision and drainage. Another 4 (40%) had spontaneously rupture of the perianal abscess. 6 (60%) of the fistula-in-ano was submuscular, 30% subcutaneous and 10% were complex or recurrent. Nearly, 20% of patients had fistulotomy and seton application for adequate drainage. Mucosal advancement flap was performed in 5 (50%) and fistulotomy in 3 (30%) patients. Another 30% had fistulotomy and continuing sitz bath. CONCLUSION: Cryptoglandular infection is an important cause of perianal abscesses and fistula-in-ano and if poorly managed results in Fournier's gangrene. Early broad spectrum parenteral antibiotic therapy and primary surgical treatment can prevent Fournier's gangrene.", "provenance": [ { "field": "n", "quote": "A total of 10 men with a mean age of 50.5 years (35-60) were managed in the period of study." }, { "field": "population", "quote": "Fistula-in-ano when complicated by Fournier's gangrene is an unusual finding and always carries high morbidity." }, { "field": "intervention", "quote": "Early broad spectrum parenteral antibiotic therapy and primary surgical treatment can prevent Fournier's gangrene." }, { "field": "comparator", "quote": "4 (40%) of these patients had inadequate drainage of their perianal abscess and 2 (20%) had incision and drainage." }, { "field": "primaryOutcome", "quote": "if poorly managed results in Fournier's gangrene" }, { "field": "result", "quote": "Early broad spectrum parenteral antibiotic therapy and primary surgical treatment can prevent Fournier's gangrene." } ] }, { "id": "pmid:22379401", "pmid": "22379401", "doi": "10.1055/s-0031-1272819", "nctId": null, "pmcid": "PMC3140329", "title": "Anorectal infection: abscess-fistula", "firstAuthor": "Abcarian", "multipleAuthors": false, "journal": "Clin Colon Rectal Surg", "year": 2011, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "adults with anorectal abscess or fistula", "intervention": "early adequate drainage of abscess; various fistula treatments including fistulotomy, setons, fibrin sealant, anal fistula plug, flaps, and LIFT procedure", "comparator": "different surgical approaches compared to each other (sphincter-cutting vs conservative, nonsphincter cutting techniques)", "primaryOutcome": "fistula formation, incontinence, and recurrence/persistence after treatment", "result": "abscesses lead to fistulas in about 40% of cases; conservative, nonsphincter cutting procedures have more recurrence/persistence than sphincter-cutting procedures, which carry incontinence risk", "resultDirection": "mixed", "quality": "very-low", "qualityWhy": "This is a general narrative review summarizing existing knowledge without original data, a defined study population, or systematic methodology.", "directness": "indirect", "relevanceNote": "", "limitations": "No original study data, sample size, or systematic review methodology; general overview rather than a prevention trial.", "followUp": "", "plainFinding": "Early drainage may limit fistula risk.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/22379401/", "sourceText": "Anorectal abscess and fistula are among the most common diseases encountered in adults. Abscess and fistula should be considered the acute and chronic phase of the same anorectal infection. Abscesses are thought to begin as an infection in the anal glands spreading into adjacent spaces and resulting in fistulas in ~40% of cases. The treatment of an anorectal abscess is early, adequate, dependent drainage. The treatment of a fistula, although surgical in all cases, is more complex due to the possibility of fecal incontinence as a result of sphincterotomy. Primary fistulotomy and cutting setons have the same incidence of fecal incontinence depending on the complexity of the fistula. So even though the aim of a surgical procedure is to cure a fistula, conservative management short of major sphincterotomy is warranted to preserve fecal incontinence. However, trading radical surgery for conservative (nonsphincter cutting) procedures such as a draining seton, fibrin sealant, anal fistula plug, endorectal advancement flap, dermal island flap, anoplasty, and LIFT (ligation of intersphincteric fistula tract) procedure all result in more recurrence/persistence requiring repeated operations in many cases. A surgeon dealing with fistulas on a regular basis must tailor various operations to the needs of the patient depending on the complexity of the fistula encountered.", "provenance": [ { "field": "population", "quote": "Anorectal abscess and fistula are among the most common diseases encountered in adults." }, { "field": "intervention", "quote": "The treatment of an anorectal abscess is early, adequate, dependent drainage." }, { "field": "intervention", "quote": "draining seton, fibrin sealant, anal fistula plug, endorectal advancement flap, dermal island flap, anoplasty, and LIFT (ligation of intersphincteric fistula tract) procedure" }, { "field": "comparator", "quote": "Primary fistulotomy and cutting setons have the same incidence of fecal incontinence depending on the complexity of the fistula." }, { "field": "primaryOutcome", "quote": "resulting in fistulas in ~40% of cases" }, { "field": "result", "quote": "trading radical surgery for conservative (nonsphincter cutting) procedures such as a draining seton, fibrin sealant, anal fistula plug, endorectal advancement flap, dermal island flap, anoplasty, and LIFT (ligation of intersphincteric fistula tract) procedure all result in more recurrence/persistence requiring repeated operations in many cases" } ] }, { "id": "pmid:21785979", "pmid": "21785979", "doi": "10.1007/s00383-011-2956-7", "nctId": null, "pmcid": null, "title": "Perianal abscess and fistula-in-ano in children: clinical characteristic, management and outcome", "firstAuthor": "Afşarlar", "multipleAuthors": true, "journal": "Pediatr Surg Int", "year": 2011, "design": "retrospective", "n": 158, "nField": "reported", "population": "children treated for perianal abscess or fistula-in-ano", "intervention": "antibiotic therapy after abscess drainage", "comparator": "drainage without antibiotics", "primaryOutcome": "development of fistula-in-ano", "result": "antibiotics significantly reduced the development of fistula-in-ano", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a retrospective chart review without randomization, so other factors could explain the difference.", "directness": "direct", "relevanceNote": "", "limitations": "Retrospective design, no randomization, and treatment choices were not standardized.", "followUp": "10.6 ± 8.6 months", "plainFinding": "Antibiotics reduced fistula formation.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/21785979/", "sourceText": "PURPOSE: The aims of this study are to evaluate the clinical characteristics of perianal abscess and fistula-in-ano in children, and to assess our experience in treatment, and to identify factors that affected the clinical outcomes. METHODS: A retrospective review of children with perianal abscess and fistula-in-ano was carried out in a tertiary care children's hospital from January 2005 to December 2010. Demographic information of the patients, localization of the lesions, treatment procedures, microbial organisms in pus, usage of antibiotics, abscess recurrence, development of fistula-in-ano, and duration of symptoms were recorded. Patients with systemic diseases and inflammatory bowel diseases were excluded from the study. RESULTS: A total of 158 children (146 males, 12 females) treated for perianal abscess and fistula-in-ano with a median age of 7.2 months (ranging 16 days to 18 years) were eligible for the study. Initial examination of the 136 patients revealed perianal abscess and 22 patients with fistula-in-ano. Primary treatment was incision and drainage (I/D) for the fluctuating perianal abscess (73.5%), and local care for the spontaneously (S/D) drained abscess (26.5%) with or without antibiotic therapy. Patients were divided into two groups according to age distribution, 98 of the patients were younger than 12 months, and 60 were older than 12 months of age. There was no significant difference in sex distribution, localization of the lesions, treatment procedures, recurrence of abscess and fistula-in-ano formation between the two age groups (p > 0.05). Recurrence rates (27% in I/D and 30.6% in S/D, p > 0.05) and development of fistula-in-ano (20% in I/D and 27.8 in S/D, p > 0.05) were not significant I/D and S/D groups. Kind of the microorganisms in pus swaps did not effect the fistula-in-ano formation. Usage of antibiotics significantly reduced the development of fistula-in-ano (p = 0.001), but did not effect the recurrence of perianal abscess (p > 0.05). The mean follow-up period was 10.6 ± 8.6 months. While the 9 of the overall 52 fistula-in-ano (22 initial, 30 after abscess treatment) were resolved spontaneously, 43 of the remaining needed surgical intervention (fistulotomy/fistulectomy). CONCLUSIONS: Although management of perianal abscess is still controversial, simple drainage of the perianal abscess with additional antibiotic therapy reduces the development of fistula-in-ano. Fistula-in-ano within children has a chance of spontaneous resolution thus the immediate surgical intervention should be avoided.", "provenance": [ { "field": "n", "quote": "A total of 158 children (146 males, 12 females) treated for perianal abscess and fistula-in-ano" }, { "field": "population", "quote": "children with perianal abscess and fistula-in-ano" }, { "field": "intervention", "quote": "Usage of antibiotics significantly reduced the development of fistula-in-ano (p = 0.001)" }, { "field": "comparator", "quote": "did not effect the recurrence of perianal abscess (p > 0.05)" }, { "field": "primaryOutcome", "quote": "development of fistula-in-ano" }, { "field": "result", "quote": "Usage of antibiotics significantly reduced the development of fistula-in-ano (p = 0.001), but did not effect the recurrence of perianal abscess (p > 0.05)" } ] }, { "id": "pmid:21730779", "pmid": "21730779", "doi": "10.1097/DCR.0b013e31821cc1f9", "nctId": null, "pmcid": null, "title": "Does adjuvant antibiotic treatment after drainage of anorectal abscess prevent development of anal fistulas? A randomized, placebo-controlled, double-blind, multicenter study", "firstAuthor": "Sözener", "multipleAuthors": true, "journal": "Dis Colon Rectum", "year": 2011, "design": "rct", "n": 151, "nField": "reported", "population": "adults who had surgical drainage of an anorectal abscess", "intervention": "antibiotics (amoxicillin-clavulanic acid) for 10 days after abscess drainage", "comparator": "placebo after abscess drainage", "primaryOutcome": "development of an anal fistula within 1 year", "result": "fistulas formed in more patients given antibiotics (37.3%) than placebo (22.4%)", "resultDirection": "harm", "quality": "moderate", "qualityWhy": "it was a randomized, placebo-controlled, double-blind multicenter trial, but many patients were lost between randomization and final analysis, weakening confidence.", "directness": "direct", "relevanceNote": "", "limitations": "Only 151 of 183 randomized patients had data available for per-protocol analysis, and the study excluded recurrent, secondary, or complicated abscesses.", "followUp": "1-year follow-up", "plainFinding": "Antibiotics did not prevent fistulas, worse rate.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/21730779/", "sourceText": "BACKGROUND: The risk of fistula formation is a major concern after incision and drainage of an anorectal abscess. OBJECTIVE: Our objective was to the test the effects of antibiotic treatment on fistula formation after incision and drainage of anorectal abscesses. DESIGN: Randomized, placebo-controlled, double-blind study. SETTING: Multicenter trial at 3 teaching hospitals in Turkey. PATIENTS: Patients who underwent abscess drainage between September 2005 and January 2008 were evaluated for eligibility. Exclusion criteria included penicillin allergy, antimicrobial agent usage before enrolment, other infection, previous anorectal surgery, inflammatory bowel disease, suspicion of Fournier gangrene, secondary and recurrent anorectal abscesses, anal fistula at time of the surgery, immune compromised states, and pregnancy. INTERVENTION: Patients were randomly assigned to receive placebo or amoxicillin-clavulanic acid combination treatment for 10 days after abscess drainage. MAIN OUTCOME MEASURES: The primary end point was rate of anorectal fistula formation at 1-year follow-up. RESULTS: : Of 334 patients assessed for eligibility, 183 entered the study (placebo, 92; antibiotics, 91). Data were available for per-protocol analysis from 151 patients (placebo, 76; antibiotics, 75) with a mean age of 37.6 years; 118 patients (78.1%) were men. Overall, 45 patients (29.8%) developed anal fistulas during 1-year follow-up. Fistula formation occurred in 17 patients (22.4%) in the placebo group and in 28 patients (37.3%) in the antibiotic group (P = .044). Risk of fistula formation was increased in patients with ischiorectal abscess (odds ratio, 7.82) or intersphincteric abscess (odds ratio, 3.35) compared with perianal abscess. CONCLUSION: Antibiotic treatment following the drainage of an anorectal abscess has no protective effect regarding risk of fistula formation.", "provenance": [ { "field": "population", "quote": "Patients who underwent abscess drainage between September 2005 and January 2008 were evaluated for eligibility." }, { "field": "intervention", "quote": "Patients were randomly assigned to receive placebo or amoxicillin-clavulanic acid combination treatment for 10 days after abscess drainage." }, { "field": "comparator", "quote": "Patients were randomly assigned to receive placebo or amoxicillin-clavulanic acid combination treatment for 10 days after abscess drainage." }, { "field": "primaryOutcome", "quote": "The primary end point was rate of anorectal fistula formation at 1-year follow-up." }, { "field": "result", "quote": "Fistula formation occurred in 17 patients (22.4%) in the placebo group and in 28 patients (37.3%) in the antibiotic group (P = .044)." }, { "field": "n", "quote": "Data were available for per-protocol analysis from 151 patients (placebo, 76; antibiotics, 75)" } ] }, { "id": "pmid:20632016", "pmid": "20632016", "doi": "10.1007/s00383-010-2664-8", "nctId": null, "pmcid": null, "title": "Usefulness of bFGF spray in the treatment of perianal abscess and fistula-in-ano", "firstAuthor": "Kubota", "multipleAuthors": true, "journal": "Pediatr Surg Int", "year": 2010, "design": "case-series", "n": 9, "nField": "reported", "population": "infant boys with perianal abscess", "intervention": "bFGF spray applied to the abscess", "comparator": "none", "primaryOutcome": "resolution of pus discharge and swelling, and recurrence", "result": "all patients improved, with pus and swelling resolving in about a week, and most had no recurrence over roughly 14 months", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This was a very small study of only nine patients with no comparison group, so it can't reliably show whether the treatment actually works.", "directness": "indirect", "relevanceNote": "", "limitations": "small sample size, no control group, no randomization", "followUp": "14.1 ± 3.2 months", "plainFinding": "Faster healing, few recurrences", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/20632016/", "sourceText": "PURPOSE: Basic fibroblast growth factor (bFGF) is a newly identified recombinant agent that promotes wound healing through an augmented neovascularization. This study examined the effect of bFGF in the treatment of perianal abscesses. PATIENTS AND METHODS: Nine consecutive males with an average age of 5.1 months (1-9 months) who presented with perianal abscess in the past 2 years were treated with bFGF (Transfermin, Kaken Co., Ltd., Tokyo, Japan). Two or three sprays of bFGF were applied to the perianal abscess two times a day. RESULTS: All nine patients responded well to the bFGF treatment. Pus discharge and local swelling around the fistula subsided within a mean of 7.3 ± 1.9 days (1 SD) after the initiation of treatment. One case showed a mild relapse 7 months after treatment and the other developed a new lesion 1 month after treatment. However, these lesions also similarly disappeared after a second treatment with bFGF without a recurrence in the follow-up examinations at 11 and 10 months, respectively. The remaining seven cases have all done well without any recurrence at a mean follow-up period of 14.1 ± 3.2 months. CONCLUSION: These results clearly indicate the usefulness of the bFGF spray as a new treatment strategy for the management of perianal abscesses.", "provenance": [ { "field": "n", "quote": "Nine consecutive males with an average age of 5.1 months" }, { "field": "population", "quote": "Nine consecutive males with an average age of 5.1 months (1-9 months) who presented with perianal abscess" }, { "field": "intervention", "quote": "Two or three sprays of bFGF were applied to the perianal abscess two times a day." }, { "field": "comparator", "quote": "PATIENTS AND METHODS: Nine consecutive males with an average age of 5.1 months (1-9 months) who presented with perianal abscess in the past 2 years were treated with bFGF" }, { "field": "primaryOutcome", "quote": "Pus discharge and local swelling around the fistula subsided within a mean of 7.3 ± 1.9 days" }, { "field": "result", "quote": "All nine patients responded well to the bFGF treatment." }, { "field": "result", "quote": "The remaining seven cases have all done well without any recurrence at a mean follow-up period of 14.1 ± 3.2 months." } ] }, { "id": "pmid:20614450", "pmid": "20614450", "doi": "10.1002/14651858.CD006827.pub2", "nctId": null, "pmcid": "PMC13270907", "title": "Incision and drainage of perianal abscess with or without treatment of anal fistula", "firstAuthor": "Malik", "multipleAuthors": true, "journal": "Cochrane Database Syst Rev", "year": 2010, "design": "meta-analysis", "n": 479, "nField": "reported", "population": "patients with perianal abscess", "intervention": "surgery to treat the anal fistula at the same time as draining the abscess", "comparator": "draining the abscess alone without fistula treatment", "primaryOutcome": "recurrent or persistent abscess/fistula needing repeat surgery, and incontinence", "result": "significantly fewer recurrences or repeat surgeries when fistula was treated at the same time, with no significant increase in incontinence", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "this pools six randomized trials but with only 479 patients total and some inconsistency between trials on the incontinence outcome", "directness": "direct", "relevanceNote": "", "limitations": "heterogeneity between trials on incontinence outcome, and small number of included trials", "followUp": "one year", "plainFinding": "Fewer repeat abscesses with fistula surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/20614450/", "sourceText": "BACKGROUND: The perianal abscess is a common surgical problem. A third of perianal abscesses may manifest a fistula-in-ano which increases the risk of abscess recurrence requiring repeat surgical drainage. Treating the fistula at the same time as incision and drainage of the abscess may reduce the likelihood of recurrent abscess and the need for repeat surgery. However, this could affect sphincter function in some patients who may not have later developed a fistula-in-ano. OBJECTIVES: We aimed to review the available randomised controlled trial evidence comparing incision and drainage of perianal abscess with or without fistula treatment. SEARCH STRATEGY: Randomised trials were identified from MEDLINE, EMBASE, the Cochrane Library, and reference lists of published papers and reviews. SELECTION CRITERIA: Trials comparing outcome after fistula surgery with drainage of perianal abscess compared with drainage alone were included in the review. DATA COLLECTION AND ANALYSIS: The primary outcomes were recurrent or persistent abscess/fistula which may require repeat surgery and short-term and long-term incontinence. Secondary outcomes were duration of hospitalisation, duration of wound healing, postoperative pain, quality of life scores. For dichotomous variables, relative risks and their confidence intervals were calculated. MAIN RESULTS: We identified six trials, involving 479 subjects, comparing incision and drainage of perianal abscess alone versus incision and drainage with fistula treatment. Metaanalysis showed a significant reduction in recurrence, persistent abscess/fistula or repeat surgery in favour of fistula surgery at the time of abscess incision and drainage (RR=0.13, 95% Confidence Interval of RR = 0.07-0.24). Transient manometric reduction in anal sphincter pressures, without clinical incontinence, may occur after treatment of low fistulae with abscess drainage. Incontinence at one year following drainage with fistula surgery was not statistically significant (pooled RR 3.06, 95% Confidence Interval 0.7-13.45) with heterogeneity demonstrable between the trials (Chi(2) =5.39,df=3, p=0.14, I(2) =44.4%). AUTHORS' CONCLUSIONS: The published evidence shows fistula surgery with abscess drainage significantly reduces recurrence or persistence of abscess/fistula, or the need for repeat surgery. There was no statistically significant evidence of incontinence following fistula surgery with abscess drainage. This intervention may be recommended in carefully selected patients.", "provenance": [ { "field": "n", "quote": "We identified six trials, involving 479 subjects" }, { "field": "population", "quote": "The perianal abscess is a common surgical problem." }, { "field": "intervention", "quote": "comparing incision and drainage of perianal abscess alone versus incision and drainage with fistula treatment" }, { "field": "comparator", "quote": "comparing incision and drainage of perianal abscess alone versus incision and drainage with fistula treatment" }, { "field": "primaryOutcome", "quote": "The primary outcomes were recurrent or persistent abscess/fistula which may require repeat surgery and short-term and long-term incontinence." }, { "field": "result", "quote": "Metaanalysis showed a significant reduction in recurrence, persistent abscess/fistula or repeat surgery in favour of fistula surgery at the time of abscess incision and drainage (RR=0.13, 95% Confidence Interval of RR = 0.07-0.24)." }, { "field": "result", "quote": "Incontinence at one year following drainage with fistula surgery was not statistically significant (pooled RR 3.06, 95% Confidence Interval 0.7-13.45)" } ] }, { "id": "pmid:19279415", "pmid": "19279415", "doi": "10.1007/DCR.0b013e31819a5c52", "nctId": null, "pmcid": null, "title": "Who is at risk for developing chronic anal fistula or recurrent anal sepsis after initial perianal abscess?", "firstAuthor": "Hamadani", "multipleAuthors": true, "journal": "Dis Colon Rectum", "year": 2009, "design": "retrospective", "n": 148, "nField": "reported", "population": "patients with a first-time perianal abscess", "intervention": "no specific intervention; study examined risk factors (age, diabetes, antibiotics, smoking, HIV status)", "comparator": "patients without each risk factor (e.g., age ≥40, diabetics, non-smokers)", "primaryOutcome": "developing chronic anal fistula or recurrent anal sepsis", "result": "younger age (<40) increased recurrence risk; diabetics had lower risk; antibiotics, smoking, gender, and HIV status made no significant difference", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "This was a retrospective study without randomization, so it can show patterns but not prove what prevents fistulas.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective cohort design; cannot establish causation, only associations with recurrence risk.", "followUp": "38 months", "plainFinding": "Antibiotics did not prevent recurrence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/19279415/", "sourceText": "PURPOSE: This study was designed to determine factors that contribute to chronic anal fistula or recurrent sepsis after initial perianal abscess. METHODS: A retrospective cohort study was conducted in patients with a first-time perianal abscess who were treated at Kaiser Permanente Los Angeles between 1995 and 2007. Univariate and multivariable analyses were performed with the Cox proportional hazards model to determine predictors of risk for recurrent disease. RESULTS: One hundred and forty-eight patients met inclusion criteria (105 men, 43 women; mean age, 43.6 years). During a mean follow-up of 38 months, the cumulative incidence of chronic anal fistula or recurrent sepsis was 36.5 percent. Univariate and multivariable analyses showed more than two-fold increased risk of recurrence in patients <40 years vs. those >/=40 years (P < 0.01), and univariate analysis showed nondiabetics were 2.69 times as likely to experience recurrence as diabetics (P = 0.04). No significant differences in risk of recurrence were noted for men vs. women (HR = 0.78; P = 0.39), nonsmokers vs. smokers (HR = 1.17; P = 0.58); perioperative antibiotics vs. no antibiotics (HR = 1.51; P = 0.19); or HIV-positive vs. HIV- negative status (HR = 0.72; P = 0.44). CONCLUSIONS: Age younger than 40 years significantly increased risk of chronic anal fistula or recurrent anal sepsis after a first-time episode of perianal abscess. Patients with diabetes may have a decreased risk compared with nondiabetic patients. Gender, smoking history, perioperative antibiotic treatment, and HIV status were not risk factors for chronic anal fistula or recurrent anal sepsis.", "provenance": [ { "field": "n", "quote": "One hundred and forty-eight patients met inclusion criteria" }, { "field": "population", "quote": "patients with a first-time perianal abscess who were treated at Kaiser Permanente Los Angeles between 1995 and 2007" }, { "field": "intervention", "quote": "perioperative antibiotics vs. no antibiotics" }, { "field": "comparator", "quote": "nondiabetics were 2.69 times as likely to experience recurrence as diabetics" }, { "field": "primaryOutcome", "quote": "chronic anal fistula or recurrent sepsis after initial perianal abscess" }, { "field": "result", "quote": "Age younger than 40 years significantly increased risk of chronic anal fistula or recurrent anal sepsis after a first-time episode of perianal abscess. Patients with diabetes may have a decreased risk compared with nondiabetic patients. Gender, smoking history, perioperative antibiotic treatment, and HIV status were not risk factors for chronic anal fistula or recurrent anal sepsis." } ] }, { "id": "pmid:15616754", "pmid": "15616754", "doi": "10.1007/s10350-004-0844-0", "nctId": null, "pmcid": null, "title": "Perianal abscess and fistula-in-ano in infants: a different entity?", "firstAuthor": "Serour", "multipleAuthors": true, "journal": "Dis Colon Rectum", "year": 2005, "design": "retrospective", "n": 98, "nField": "reported", "population": "infants under 2 years old with perianal abscess or anal fistula", "intervention": "antibiotics given after draining the abscess", "comparator": "drainage of the abscess alone without antibiotics", "primaryOutcome": "whether the infant later developed an anal fistula", "result": "fewer infants developed a fistula when given antibiotics after drainage (27.9%) compared with drainage alone (66.7%)", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a retrospective chart review in infants, not a randomized study, so other differences between groups could explain the result.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective design, no randomization, and the study is in infants which may differ from the general population asking about fistula prevention.", "followUp": "", "plainFinding": "Antibiotics after drainage reduced fistula risk.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/15616754/", "sourceText": "PURPOSE: The features of perianal abscess and fistula-in-ano in infants are different from those of older children, and there is controversy regarding their treatment. The aim of this study was to assess the efficacy of various methods used for their management. METHODS: A retrospective analysis of the records was conducted for all infants younger than 24 months of age treated for perianal abscess, fistula-in-ano, or both from 1990 to 2002. RESULTS: The study included 98 infants. Perianal abscess was found in 77 patients (75 males), and fistula-in-ano in 21. No infant had an underlying illness. Drainage was performed by needle aspiration in 47 patients and by incision and drainage in 5. Following drainage, 43 patients received antibiotics. Altogether, 6 infants were treated with antibiotics alone and 19 with local care alone. Twenty-eight boys (36.4 percent) had an evolution toward fistula-in-ano. Patients who received antibiotics following drainage were less likely to develop fistula-in-ano than were patients who underwent a drainage procedure alone (27.9 percent vs. 66.7 percent, P < 0.05). All patients with fistula-in-ano were male and had been previously treated for perianal abscess (21 patients elsewhere and 28 in our department). Spontaneous cure of fistula-in-ano occurred in 42.9 percent of them (average 3.2 months), and 57.1 percent underwent fistulectomy for persistent fistula-in-ano. Cryptotomy was added when an involved crypt was found (11 patients, 39.3 percent). No recurrence of fistula-in-ano was noted after fistulectomy. CONCLUSIONS: Local treatment for perianal abscess during the early stage and drainage by needle aspiration during the progressive stage are effective. Antibiotics may be considered for patients undergoing drainage of perianal abscess. Fistula-in-ano can be managed conservatively for one to three months. For a persisting fistula, fistulectomy with cryptotomy (when abnormal anal crypts are found) is the preferred treatment.", "provenance": [ { "field": "n", "quote": "The study included 98 infants." }, { "field": "population", "quote": "all infants younger than 24 months of age treated for perianal abscess, fistula-in-ano, or both" }, { "field": "intervention", "quote": "Following drainage, 43 patients received antibiotics." }, { "field": "comparator", "quote": "Patients who received antibiotics following drainage were less likely to develop fistula-in-ano than were patients who underwent a drainage procedure alone" }, { "field": "primaryOutcome", "quote": "Twenty-eight boys (36.4 percent) had an evolution toward fistula-in-ano." }, { "field": "result", "quote": "27.9 percent vs. 66.7 percent, P < 0.05" } ] }, { "id": "pmid:12746675", "pmid": "12746675", "doi": null, "nctId": null, "pmcid": null, "title": "[Perianal abcess in infant]", "firstAuthor": "Barthés-Anidjar", "multipleAuthors": true, "journal": "Ann Dermatol Venereol", "year": 2003, "design": "case-series", "n": 1, "nField": "reported", "population": "7-week-old baby boy with a perianal abscess", "intervention": "surgical drainage of the abscess", "comparator": "no comparison group", "primaryOutcome": "whether a fistula formed or came back after treatment", "result": "no fistula found during surgery and no recurrence afterward", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single infant case report, so it cannot reliably show what prevents fistula formation in general.", "directness": "direct", "relevanceNote": "", "limitations": "only one patient reported, no comparison group, and the abstract notes a congenital or hormonal cause is only suspected, not proven.", "followUp": "", "plainFinding": "Drainage alone, no fistula developed.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/12746675/", "sourceText": "INTRODUCTION: Perianal abcess and fistula-in-ano are particular when happening in infants of less than 1 year of age. A congenital abnormality of crypts of Morgagni may be at the origin of the disease. There is no evidence for predisposing condition at this age. CASE REPORT: A 7-week-old boy had a painful swollen perianal lesion suggesting the presence of perianal abcess. Biological tests did not show any neutropenia nor inflammatory syndrome. The infant was admitted to the surgical center to undergo a perianal abcess drainage. During the intervention, no fistula was found. No recurrence was observed. DISCUSSION: Perianal abcess and/or fistula-in-ano are relatively common conditions in infants of less than 1 year of age. This disease is suspected to originate from anal cryptitis, which will later form a perianal abcess. Androgen excess during the foetal stage could be the cause of the formation of abnormal crypts of Morgagni, which encourages cryptitis and abcess formation. In childhood some predisposing factors can exist, as immunodeficiency or colopathy. On the opposite, a predisposing condition is rare in infancy. Twenty-eight to 85 per cent of infants with perianal abcess may progress to form a fistula. The usual treatment of perianal abcess is incision and drainage; it may be completed by fistulotomy or fistulectomy. The antibiotherapy is not systematic. The identification of the corresponding crypt may be important to avoid recurrence. On the opposite, a recent prospective study proposes a non operative management of perianal abcess and fistula-in-ano in healthy infants.", "provenance": [ { "field": "population", "quote": "A 7-week-old boy had a painful swollen perianal lesion suggesting the presence of perianal abcess." }, { "field": "intervention", "quote": "The infant was admitted to the surgical center to undergo a perianal abcess drainage." }, { "field": "comparator", "quote": "During the intervention, no fistula was found." }, { "field": "primaryOutcome", "quote": "No recurrence was observed." }, { "field": "result", "quote": "During the intervention, no fistula was found. No recurrence was observed." }, { "field": "n", "quote": "A 7-week-old boy had a painful swollen perianal lesion" } ] }, { "id": "pmid:12598965", "pmid": "12598965", "doi": "10.1007/s00383-002-0761-z", "nctId": null, "pmcid": null, "title": "Perianal abscess in childhood", "firstAuthor": "Murthi", "multipleAuthors": true, "journal": "Pediatr Surg Int", "year": 2002, "design": "retrospective", "n": 33, "nField": "reported", "population": "children with perianal abscess", "intervention": "fistulotomy (laying open a fistula tract) performed at the same time as initial abscess drainage", "comparator": "incision and drainage of the abscess alone", "primaryOutcome": "recurrence as fistula-in-ano or repeat perianal abscess", "result": "no recurrences occurred when fistulotomy was done at the same time as drainage, while all recurrences occurred in children treated by drainage alone", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a small retrospective chart review without randomization, so other factors could explain the difference", "directness": "direct", "relevanceNote": "", "limitations": "retrospective design, small sample size, not randomized", "followUp": "", "plainFinding": "Fistulotomy at drainage prevented fistula recurrence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/12598965/", "sourceText": "Perianal abscess (PA) is a common condition encountered in childhood, but its optimal primary treatment is uncertain. Treatment of PA by incision and drainage (I & D) alone is associated with an unacceptably high recurrence rate, either as fistula-in-ano (FIA) or as PA. To identify possible causes of recurrence and assess the value of concomitant laying open of a fistulous tract at the time of primary incision and drainage, the case notes of all children who presented to our institution with a PA between January 1992 and January 1997 were reviewed retrospectively. Thirty-three cases were identified (29 boys and 4 girls). A fistulous tract was identified and laid open at the time of primary drainage in 20 cases, whilst 13 were treated by I & D alone. Following primary drainage, there were 7 recurrences (21.2%) (FIA 5 and PA 2). All recurrences had been primarily treated by drainage alone, whilst there were no recurrences in patients who had also undergone fistulotomy at the time of primary drainage. Thus the primary treatment of PA in childhood should involve a careful search for a coexisting fistula and treatment of this by fistulotomy.", "provenance": [ { "field": "n", "quote": "Thirty-three cases were identified (29 boys and 4 girls)." }, { "field": "population", "quote": "the case notes of all children who presented to our institution with a PA between January 1992 and January 1997 were reviewed retrospectively." }, { "field": "intervention", "quote": "A fistulous tract was identified and laid open at the time of primary drainage in 20 cases" }, { "field": "comparator", "quote": "whilst 13 were treated by I & D alone." }, { "field": "primaryOutcome", "quote": "Following primary drainage, there were 7 recurrences (21.2%) (FIA 5 and PA 2)." }, { "field": "result", "quote": "All recurrences had been primarily treated by drainage alone, whilst there were no recurrences in patients who had also undergone fistulotomy at the time of primary drainage." } ] }, { "id": "pmid:10873039", "pmid": "10873039", "doi": "10.1053/jpsu.2000.6931", "nctId": null, "pmcid": null, "title": "The nonoperative management of fistula-in-ano", "firstAuthor": "Rosen", "multipleAuthors": true, "journal": "J Pediatr Surg", "year": 2000, "design": "case-series", "n": 18, "nField": "reported", "population": "male infants with perianal abscess or fistula", "intervention": "conservative, nonoperative management (observation, drainage only if uncomfortable or feverish)", "comparator": "standard fistulotomy (surgical treatment), not directly tested in this study", "primaryOutcome": "whether fistulas healed without surgery", "result": "77% of infants developed fistulas, and all of these healed without any operation; no antibiotics were needed", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This is a small, single-arm study of only 18 infants with no comparison group, so it can't firmly prove conservative care is better than surgery.", "directness": "indirect", "relevanceNote": "", "limitations": "Small sample size, no control group, single-institution prospective case series.", "followUp": "Mean follow-up period was 37 months", "plainFinding": "Fistulas healed without surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/10873039/", "sourceText": "BACKGROUND/PURPOSE: Fistulotomy is the accepted treatment for infants with perianal fistula. Although recurrence rates range from 0% to 68%. Based on the experience of a senior colleague who noted that babies suffering from perianal fistula follow a self-limited course the authors decided to determine if this observation was accurate. METHODS: A conservative approach to perianal abscess and fistula was used prospectively in 18 male infants. Abscesses were to be drained only if the baby was very uncomfortable or febrile. Once a fistula developed the authors continued observation until the fistula healed. Data are expressed as mean +/- SD. Mean follow-up period was 37 months. RESULTS: Mean age at onset of symptoms was 4 +/- 3 months. Fistulas developed in 14 patients (77%). All fistulas healed without operation. Four patients had abscesses drained for discomfort (n = 3) or fever (n = 1). No patient required antibiotics. Mean duration of symptoms was 6 +/- 4 months. Four patients in whom fistulas did not form healed after incision (n = 3) or spontaneous drainage (n = 1). All patients currently are asymptomatic. CONCLUSIONS: In healthy neonates, perianal abscess and fistula are self-limited conditions rarely requiring surgical drainage and not requiring antibiotics. The conservative management of perianal abscess and fistula in healthy infants appears to be safe and effective.", "provenance": [ { "field": "n", "quote": "A conservative approach to perianal abscess and fistula was used prospectively in 18 male infants." }, { "field": "population", "quote": "18 male infants" }, { "field": "intervention", "quote": "Abscesses were to be drained only if the baby was very uncomfortable or febrile." }, { "field": "comparator", "quote": "Fistulotomy is the accepted treatment for infants with perianal fistula." }, { "field": "primaryOutcome", "quote": "Once a fistula developed the authors continued observation until the fistula healed." }, { "field": "result", "quote": "Fistulas developed in 14 patients (77%). All fistulas healed without operation." }, { "field": "followUp", "quote": "Mean follow-up period was 37 months." } ] }, { "id": "pmid:10867462", "pmid": "10867462", "doi": "10.1159/000018847", "nctId": null, "pmcid": null, "title": "The initial approach to anorectal abscesses: fistulotomy is safe and reduces the chance of recurrences", "firstAuthor": "Knoefel", "multipleAuthors": true, "journal": "Dig Surg", "year": 2000, "design": "retrospective", "n": 131, "nField": "reported", "population": "people with an anal abscess or anal fistula", "intervention": "draining the abscess plus cutting open the fistula at the same time (fistulotomy)", "comparator": "draining the abscess alone without treating the fistula", "primaryOutcome": "fistula or abscess coming back, and bowel control problems", "result": "Doing fistulotomy at the same time as draining the abscess cut recurrence from 34% to 4%, and from 67% to 0% in patients having surgery for a recurrence; only 3% developed minor incontinence, and only after recurrent disease", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This is a retrospective chart review, not a randomized trial, so other differences between patients could explain the results.", "directness": "direct", "relevanceNote": "", "limitations": "Retrospective design with follow-up questionnaires, not a randomized comparison.", "followUp": "40 (range 3-78) months", "plainFinding": "Early fistulotomy cut recurrence, few incontinence issues.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/10867462/", "sourceText": "BACKGROUND/AIMS: Anorectal abscesses are most frequently based on a coexistent fistula in ano. Whether these should be searched for and excised initially or not remains controversial. Our aim was to determine which approach has less recurrences and carries a lower risk of continence disorders. METHODS: 158 patients with an anorectal abscess or anal fistula were identified in our institution over a period of 75 consecutive months. The records and follow-up questionnaires of 131 patients were evaluable. The mean follow-up period was 40 (range 3-78) months. RESULTS: When fistulotomy was performed at the time of draining the abscess, the recurrence rate could be reduced, in comparison to incision and drainage alone, from 34 to 4% (p = 0.007). In the group of patients undergoing surgery for a recurrence, the recurrence rate could even be reduced from 67 to 0% (p = 0.03) by simultaneous fistulotomy. A total of 4 of the 131 patients (3%) developed incontinence of liquid stool and flatus, but no incontinence of solid stool occurred. Incontinence did only occur after recurrent disease. CONCLUSIONS: The number of recurrences requiring surgery can be significantly reduced by initial fistulotomy. The risk to develop incontinence increases with recurrent anorectal disease, not with careful fistulotomy.", "provenance": [ { "field": "population", "quote": "158 patients with an anorectal abscess or anal fistula" }, { "field": "intervention", "quote": "When fistulotomy was performed at the time of draining the abscess" }, { "field": "comparator", "quote": "in comparison to incision and drainage alone" }, { "field": "primaryOutcome", "quote": "determine which approach has less recurrences and carries a lower risk of continence disorders" }, { "field": "result", "quote": "the recurrence rate could be reduced, in comparison to incision and drainage alone, from 34 to 4% (p = 0.007)" }, { "field": "result", "quote": "the recurrence rate could even be reduced from 67 to 0% (p = 0.03) by simultaneous fistulotomy" }, { "field": "result", "quote": "A total of 4 of the 131 patients (3%) developed incontinence of liquid stool and flatus, but no incontinence of solid stool occurred" }, { "field": "n", "quote": "The records and follow-up questionnaires of 131 patients were evaluable." }, { "field": "followUp", "quote": "The mean follow-up period was 40 (range 3-78) months." } ] }, { "id": "pmid:9607474", "pmid": "9607474", "doi": "10.1016/s0022-3468(98)90193-2", "nctId": null, "pmcid": null, "title": "Perianal abscess and fistula-in-ano in infants", "firstAuthor": "Festen", "multipleAuthors": true, "journal": "J Pediatr Surg", "year": 1998, "design": "retrospective", "n": null, "nField": "not-reported", "population": "infants with perianal abscess or fistula-in-ano", "intervention": "simple drainage of perianal abscess, or fistulotomy/fistulectomy for fistula", "comparator": "", "primaryOutcome": "development of fistula after abscess drainage, and recurrence after fistula surgery", "result": "Drainage of a perianal abscess is followed in 35% of cases by a fistula; fistulotomy or fistulectomy is followed in 13% of cases by a recurrence", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "This is a retrospective chart review with no comparison group and long-term follow-up relying on questionnaires, so the findings are not strong evidence for preventing fistulas.", "directness": "direct", "relevanceNote": "", "limitations": "Retrospective design, follow-up based on questionnaire response of only 81%, no control group to compare treatments.", "followUp": "1 to 24 year, mean 7.74 year", "plainFinding": "Drainage often leads to fistula.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/9607474/", "sourceText": "PURPOSE: The aim of this study was to obtain insight into the short- and long-term results of treatment of perianal abscess and fistula-in-ano in infants. METHODS: This is a retrospective study of the records of patients treated over a 21-year period from January 1974 until December 1994 in a Pediatric Surgical Center. A long-term (1 to 24 year, mean 7.74 year) follow-up by questionnaire (response 81%) is also included. RESULTS: Drainage of a perianal abscess is followed in 35% of cases by a fistula. Fistulotomy or fistulectomy is followed in 13% of cases by a recurrence. There were two long-term recurrences that both healed spontaneously. The persisting scar sometimes gives problems with anal cleaning. All children aged 3 years and older were continent for feces. In two, there was soiling for some time. One had constipation and one was incontinent during the night. CONCLUSIONS: Simple drainage of a perianal abscess is followed frequently by a fistula. Fistulotomy or fistulectomy of a fistula-in-ano in infants has a reasonable chance of recurrence in the short term. Long-term recurrences are exceptional. There are no serious disabilities in the long run.", "provenance": [ { "field": "population", "quote": "Perianal abscess and fistula-in-ano in infants" }, { "field": "intervention", "quote": "Drainage of a perianal abscess" }, { "field": "intervention", "quote": "Fistulotomy or fistulectomy" }, { "field": "primaryOutcome", "quote": "The aim of this study was to obtain insight into the short- and long-term results of treatment of perianal abscess and fistula-in-ano in infants." }, { "field": "result", "quote": "Drainage of a perianal abscess is followed in 35% of cases by a fistula." }, { "field": "result", "quote": "Fistulotomy or fistulectomy is followed in 13% of cases by a recurrence." }, { "field": "followUp", "quote": "1 to 24 year, mean 7.74 year" } ] }, { "id": "pmid:9247434", "pmid": "9247434", "doi": null, "nctId": null, "pmcid": null, "title": "Outcome after incision and drainage with fistulotomy for ischiorectal abscess", "firstAuthor": "Cox", "multipleAuthors": true, "journal": "Am Surg", "year": 1997, "design": "retrospective", "n": 80, "nField": "reported", "population": "patients with ischiorectal abscess", "intervention": "incision and drainage plus fistulotomy at the same time", "comparator": "incision and drainage alone", "primaryOutcome": "recurrence of abscess/fistula and change in bowel continence", "result": "lower recurrence with combined treatment but similar continence problems", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a retrospective chart review without randomization, so other factors could explain the difference.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective design, no randomization, no control for confounding factors, telephone follow-up for continence assessment.", "followUp": "44.3 months", "plainFinding": "Fewer recurrences with added fistula cut", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/9247434/", "sourceText": "Concomitant anal fistulotomy (F) and incision and drainage (I&D) of ischiorectal abscesses (IA) are often avoided, for fear of irreversibly impairing anal continence. However, failure to identify and treat the frequently associated trans-sphincteric anal fistula dooms the patient to recurrent anal suppurative disease. We have employed an aggressive approach of performing I&D and F for IA at the time of initial presentation. Adequate drainage is assured by placement of counterincisions and Penrose drains to minimize the time for healing of the perianal wound. Drainage is followed by a careful examination of the anal canal for fistula localization followed by fistulotomy, or less frequently by cutting seton placement. We present our experience with this approach to IA, with special attention paid to the evaluation of recurrence rates and anal continence. This paper represents a retrospective review of 80 patients with IA managed from 1983 to 1996. Operative records and office records were reviewed, and follow-up data were obtained by telephone interview. Internal fistulous openings were identified in 55 (68.8%) patients. Surgeries included: 38 (47.5%) I&D and F, 8 (10%) I&D and seton, and 34 (42.5%) I&D alone. Follow-up data were available on 99 per cent of patients; mean, 44.3 months. Results showed a 44 per cent recurrence rate in those who underwent I&D as compared with 21.1 per cent following I&D and F. 11.8 per cent of patients treated with I&D experienced a change in their level of continence postoperatively as compared to 15.8 per cent treated with I&D and F. The results indicate that an aggressive approach to IA allows identification of a trans-sphincteric fistula in 57.5 per cent of patients with IA. Therefore, optimal surgical management for IA appears to be I&D and F, resulting in a lower recurrence rate and comparable morbidity as compared to I&D alone.", "provenance": [ { "field": "n", "quote": "retrospective review of 80 patients with IA" }, { "field": "population", "quote": "80 patients with IA managed from 1983 to 1996" }, { "field": "intervention", "quote": "I&D and F" }, { "field": "comparator", "quote": "I&D alone" }, { "field": "primaryOutcome", "quote": "evaluation of recurrence rates and anal continence" }, { "field": "result", "quote": "a 44 per cent recurrence rate in those who underwent I&D as compared with 21.1 per cent following I&D and F" }, { "field": "followUp", "quote": "mean, 44.3 months" } ] }, { "id": "pmid:9189098", "pmid": "9189098", "doi": null, "nctId": null, "pmcid": null, "title": "Perianal sepsis in children", "firstAuthor": "Nix", "multipleAuthors": true, "journal": "Br J Surg", "year": 1997, "design": "case-series", "n": 58, "nField": "reported", "population": "children with a perianal abscess or fistula", "intervention": "incision and drainage for abscess, with fistulectomy for fistula", "comparator": "fistulotomy", "primaryOutcome": "development of an anal fistula after treatment and rate of recurrence", "result": "Fistula formation only occurred in children with enteric bacterial infection, and fistulectomy caused significantly fewer recurrences than fistulotomy", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This is a small retrospective review of 58 children from one hospital, not a controlled study, so it cannot reliably prove what prevents fistula formation.", "directness": "indirect", "relevanceNote": "", "limitations": "Retrospective, single-centre case series without a control group or randomisation, and identifiable causes were rare apart from Crohn's disease.", "followUp": "", "plainFinding": "Fistulectomy had fewer recurrences than fistulotomy", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/9189098/", "sourceText": "BACKGROUND: Perianal sepsis is a relatively common surgical problem in children and yet the contribution of rare aetiological factors, the frequency of fistula formation complicating perianal abscess, the significance of bacteriological findings and the optimum treatment of fistula in ano are poorly understood. METHODS: A consecutive series of 58 children (51 boys, seven girls) with a perianal abscess or fistula attending a tertiary referral centre over a 4-year period was reviewed. RESULTS: Thirty-eight children (34 boys, four girls), ranging in age from 1 month to 12 years, presented with an abscess. After treatment, three developed a further abscess but only four developed a fistula. Fistula formation only occurred in those with enteric bacterial infection. Of 24 children with a perianal fistula five required further surgery for recurrence, four of whom were initially treated by fistulotomy. In most patients, the fistula was simple, low and direct, and treatment by fistulectomy resulted in significantly fewer recurrences. Apart from Crohn's disease, identifiable aetiological factors were rare. CONCLUSION: Perianal sepsis is most common in otherwise healthy boys under 2 years of age. Abscess is best treated by incision and drainage, and fistulectomy is successful for the small proportion who develop a fistula.", "provenance": [ { "field": "n", "quote": "A consecutive series of 58 children (51 boys, seven girls) with a perianal abscess or fistula attending a tertiary referral centre over a 4-year period was reviewed." }, { "field": "population", "quote": "Perianal sepsis is a relatively common surgical problem in children" }, { "field": "intervention", "quote": "Abscess is best treated by incision and drainage, and fistulectomy is successful for the small proportion who develop a fistula." }, { "field": "comparator", "quote": "Of 24 children with a perianal fistula five required further surgery for recurrence, four of whom were initially treated by fistulotomy." }, { "field": "primaryOutcome", "quote": "the frequency of fistula formation complicating perianal abscess" }, { "field": "result", "quote": "Fistula formation only occurred in those with enteric bacterial infection." }, { "field": "result", "quote": "treatment by fistulectomy resulted in significantly fewer recurrences" } ] }, { "id": "pmid:9106694", "pmid": "9106694", "doi": "10.1007/BF02258390", "nctId": null, "pmcid": null, "title": "Perianal abscess in Crohn's disease", "firstAuthor": "Makowiec", "multipleAuthors": true, "journal": "Dis Colon Rectum", "year": 1997, "design": "prospective-cohort", "n": 126, "nField": "reported", "population": "patients with perianal Crohn's disease", "intervention": "having a fecal diversion (stoma) and type of surgical drainage (seton, catheter, or incision)", "comparator": "patients without a stoma and different anal fistula types", "primaryOutcome": "occurrence and recurrence of perianal abscess", "result": "abscess recurrence was much lower in patients with a stoma (13% vs 60% without stoma) and in those with superficial fistulas; long-term seton use did not prevent recurrence", "resultDirection": "mixed", "quality": "moderate", "qualityWhy": "it was a prospective observational study without randomization, so other factors could explain the differences seen.", "directness": "indirect", "relevanceNote": "", "limitations": "observational design without randomization; focuses on abscess recurrence in patients who already have perianal fistulizing Crohn's disease rather than preventing new fistula formation", "followUp": "32 +/- 17 months", "plainFinding": "Stoma cut abscess recurrence.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/9106694/", "sourceText": "PURPOSE: Perianal disease is frequent in patients with Crohn's disease, and many of these patients will eventually have abscess formation. In a prospective follow-up study, we evaluated factors influencing the occurrence and recurrence of perianal abscesses. METHODS: Of 126 consecutive patients with perianal Crohn's disease seen regularly in an outpatient clinic, 61 (48.4 percent) had at least one perianal abscess (mean follow-up, 32 +/- 17 months). In all, 110 episodes of an abscess with 145 anatomically distinct abscesses were documented. RESULTS: The occurrence of first abscesses was dependent on the type of anal fistula (ischiorectal, 73 percent; transsphincteric, 50 percent; superficial, 25 percent; P < 0.02). Surgical therapy consisted of seton drainage (34 percent), mushroom catheter drainage (49 percent), or incision and drainage (29 percent) and led to inactivation in all patients. Cumulative two-year recurrence rates after the first and second abscess were 54 and 62 percent, respectively. Abscess recurrence was less frequent in patients with a stoma (13 vs. 60 percent in patients without stoma after two years) and in patients with superficial anal fistulas (0 vs. 55 percent/56 percent in patients with transsphincteric/ischiorectal fistulas). Only two abscesses recurred within one year after removal of seton drainage, whereas 13 abscesses recurred with the seton still in place. Neither intestinal nor rectal activity of Crohn's disease significantly influenced the occurrence of an abscess. During the study period, only two patients developed partial stool incontinence. CONCLUSION: Development of perianal abscesses in Crohn's disease depends on the fecal stream and the anatomic type of anal fistula. Seton and catheter drainage are safe and highly effective in treatment. Long-term use of setons to prevent recurrent abscesses is not supported by our data.", "provenance": [ { "field": "population", "quote": "126 consecutive patients with perianal Crohn's disease seen regularly in an outpatient clinic" }, { "field": "n", "quote": "Of 126 consecutive patients with perianal Crohn's disease" }, { "field": "intervention", "quote": "Abscess recurrence was less frequent in patients with a stoma" }, { "field": "comparator", "quote": "13 vs. 60 percent in patients without stoma after two years" }, { "field": "primaryOutcome", "quote": "we evaluated factors influencing the occurrence and recurrence of perianal abscesses" }, { "field": "result", "quote": "Abscess recurrence was less frequent in patients with a stoma (13 vs. 60 percent in patients without stoma after two years) and in patients with superficial anal fistulas (0 vs. 55 percent/56 percent in patients with transsphincteric/ischiorectal fistulas)." } ] }, { "id": "pmid:9574424", "pmid": "9574424", "doi": null, "nctId": null, "pmcid": null, "title": "[Pyogenic periproctitis infections in childhood]", "firstAuthor": "Schaarschmidt", "multipleAuthors": true, "journal": "Langenbecks Arch Chir Suppl Kongressbd", "year": 1997, "design": "case-series", "n": 128, "nField": "reported", "population": "children with pus-filled perianal (around-the-anus) infections", "intervention": "surgical drainage (deroofing) of anal abscesses", "comparator": "not reported", "primaryOutcome": "development of an anal fistula after abscess treatment", "result": "five children developed an anal fistula after deroofing of anal abscesses, and a quarter had a recurrence of abscess", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a small, uncontrolled case series without any comparison group, so it can't show what actually prevents fistulas.", "directness": "indirect", "relevanceNote": "", "limitations": "No comparator group, no test of any preventive intervention; just observed outcomes after standard abscess drainage.", "followUp": "3 weeks and 3 years", "plainFinding": "Few developed fistulas after drainage.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/9574424/", "sourceText": "A total of 128 pediatric pyogenic perianal infections were recorded prospectively in 1984-1995; over 70% arose in children below the age of 2 years. A quarter of all perianal abscesses developed a recurrence between 3 weeks and 3 years after the initial operation, while five children had an anal fistula after deroofing of anal abscesses. The early age of onset and frequent anomaly of anal crypts (12%) suggests a partly congenital etiology due to impaired fusion of the proctodaeal membrane or rudimentary anorectal duplications for both conditions.", "provenance": [ { "field": "n", "quote": "A total of 128 pediatric pyogenic perianal infections were recorded prospectively in 1984-1995" }, { "field": "population", "quote": "A total of 128 pediatric pyogenic perianal infections were recorded prospectively in 1984-1995" }, { "field": "intervention", "quote": "five children had an anal fistula after deroofing of anal abscesses" }, { "field": "comparator", "quote": "five children had an anal fistula after deroofing of anal abscesses" }, { "field": "primaryOutcome", "quote": "five children had an anal fistula after deroofing of anal abscesses" }, { "field": "result", "quote": "A quarter of all perianal abscesses developed a recurrence between 3 weeks and 3 years after the initial operation, while five children had an anal fistula after deroofing of anal abscesses." }, { "field": "followUp", "quote": "between 3 weeks and 3 years after the initial operation" } ] }, { "id": "pmid:7611980", "pmid": "7611980", "doi": "10.1111/j.1445-2197.1995.tb01804.x", "nctId": null, "pmcid": null, "title": "Fistula-in-ano: an unusual presentation of chronic schistosomiasis", "firstAuthor": "Georghiou", "multipleAuthors": true, "journal": "Aust N Z J Surg", "year": 1995, "design": "case-series", "n": 1, "nField": "reported", "population": "a 30 year old Ethiopian man with recurrent perianal abscess and fistula-in-ano caused by schistosomiasis", "intervention": "treatment of the schistosomiasis infection with the drug praziquantel", "comparator": "no comparison group reported", "primaryOutcome": "whether treating the underlying schistosomiasis prevents further fistula complications", "result": "the abstract only suggests that treatment may prevent further complications; it does not report an actual outcome of giving praziquantel", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a single patient case report with no control group and no reported treatment outcome, so it carries very little weight.", "directness": "indirect", "relevanceNote": "", "limitations": "Single case report describing a rare parasitic cause of fistula-in-ano, with no data on whether treatment actually prevented recurrence or future fistula formation.", "followUp": "", "plainFinding": "Possible fistula prevention, not proven.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/7611980/", "sourceText": "A 30 year old Ethiopian man presented with recurrent perianal abscess and fistula-in-ano. Ova of Schistosoma mansoni were found on fecal microscopy, and were subsequently identified in fibrous tissue excised from the fistula tract. Chronic schistosomiasis should be recognized as a rare cause of fistula-in-ano. Treatment of schistosomiasis with praziquantel may prevent further complications of this condition.", "provenance": [ { "field": "n", "quote": "A 30 year old Ethiopian man presented with recurrent perianal abscess and fistula-in-ano." }, { "field": "population", "quote": "A 30 year old Ethiopian man presented with recurrent perianal abscess and fistula-in-ano. Ova of Schistosoma mansoni were found on fecal microscopy" }, { "field": "intervention", "quote": "Treatment of schistosomiasis with praziquantel may prevent further complications of this condition." }, { "field": "comparator", "quote": "Treatment of schistosomiasis with praziquantel may prevent further complications of this condition." }, { "field": "primaryOutcome", "quote": "Treatment of schistosomiasis with praziquantel may prevent further complications of this condition." }, { "field": "result", "quote": "Treatment of schistosomiasis with praziquantel may prevent further complications of this condition." } ] }, { "id": "pmid:3587696", "pmid": "3587696", "doi": null, "nctId": null, "pmcid": null, "title": "Primary partial internal sphincterectomy in the treatment of anorectal abscess", "firstAuthor": "Schouten", "multipleAuthors": true, "journal": "Neth J Surg", "year": 1987, "design": "case-series", "n": 74, "nField": "reported", "population": "patients with anorectal abscess", "intervention": "incision and drainage plus partial internal sphincterectomy", "comparator": "none (compared to historical simple incision and drainage)", "primaryOutcome": "recurrence of abscess or development of chronic anal fistula", "result": "no recurrent abscesses or persistent fistulas occurred", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a small, uncontrolled case series without randomization or a comparison group, so it can't reliably show the procedure works.", "directness": "direct", "relevanceNote": "", "limitations": "No control group, not randomized, no blinding, and no follow-up duration given.", "followUp": "", "plainFinding": "No fistulas after added sphincter cut.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/3587696/", "sourceText": "Anorectal abscess is usually treated by simple incision and drainage. Many patients treated in this way will develop a recurrence of the abscess or a chronic anal fistula. In order to prevent such a recurrence partial internal sphincterectomy has been added to the incision and drainage. The results with this so-called primary partial internal sphincterectomy in 74 patients were excellent, because of absence of recurrent abscess or persistent fistula.", "provenance": [ { "field": "population", "quote": "Anorectal abscess is usually treated by simple incision and drainage." }, { "field": "intervention", "quote": "partial internal sphincterectomy has been added to the incision and drainage" }, { "field": "comparator", "quote": "Anorectal abscess is usually treated by simple incision and drainage." }, { "field": "primaryOutcome", "quote": "Many patients treated in this way will develop a recurrence of the abscess or a chronic anal fistula." }, { "field": "result", "quote": "The results with this so-called primary partial internal sphincterectomy in 74 patients were excellent, because of absence of recurrent abscess or persistent fistula." }, { "field": "n", "quote": "in 74 patients" } ] }, { "id": "pmid:6697831", "pmid": "6697831", "doi": "10.1007/BF02553995", "nctId": null, "pmcid": null, "title": "The incidence of recurrent abscesses or fistula-in-ano following anorectal suppuration", "firstAuthor": "Vasilevsky", "multipleAuthors": true, "journal": "Dis Colon Rectum", "year": 1984, "design": "retrospective", "n": 117, "nField": "reported", "population": "patients who had incision and drainage for an anorectal abscess", "intervention": "incision and drainage of the abscess alone, without fistulotomy at the time", "comparator": "no separate comparator group; outcomes tracked over time in the same patients", "primaryOutcome": "whether a recurrent abscess or fistula-in-ano developed afterward", "result": "48% of those with perianal or ischiorectal abscesses later developed a fistula or recurrent abscess, while none with intersphincteric abscesses did", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a retrospective chart review without a comparison group, so it can show how often fistulas occur after drainage but cannot prove what prevents them.", "directness": "indirect", "relevanceNote": "", "limitations": "retrospective design, no control group, and no direct test of a preventive intervention like primary fistulotomy", "followUp": "", "plainFinding": "Fistula developed in about half.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/6697831/", "sourceText": "To determine whether primary fistulotomy should be performed at the time of incision and drainage of anorectal abscesses, a retrospective study of 117 patients who underwent incision and drainage of anorectal abscesses was conducted to ascertain what percentage of patients would subsequently develop a fistula-in-ano or recurrent abscess. None of the patients treated for intersphincteric abscesses developed recurrences. Of the 83 patients with perianal or ischiorectal abscesses, nine (11 per cent) developed recurrent abscesses and 31 (37 per cent) developed persistent fistula-in-ano for a combined persistence or recurrence rate of 48 per cent. These data support the policy of secondary fistulotomy to avoid division of sphincter muscle in the 52 per cent of patients who would not need it. In addition, the vast majority of perianal and ischiorectal abscesses can be drained under local anesthesia and hence a general anesthetic and hospital admission are obviated.", "provenance": [ { "field": "population", "quote": "117 patients who underwent incision and drainage of anorectal abscesses" }, { "field": "intervention", "quote": "incision and drainage of anorectal abscesses" }, { "field": "comparator", "quote": "a retrospective study of 117 patients who underwent incision and drainage of anorectal abscesses was conducted to ascertain what percentage of patients would subsequently develop a fistula-in-ano or recurrent abscess" }, { "field": "primaryOutcome", "quote": "what percentage of patients would subsequently develop a fistula-in-ano or recurrent abscess" }, { "field": "result", "quote": "Of the 83 patients with perianal or ischiorectal abscesses, nine (11 per cent) developed recurrent abscesses and 31 (37 per cent) developed persistent fistula-in-ano for a combined persistence or recurrence rate of 48 per cent." }, { "field": "n", "quote": "117 patients who underwent incision and drainage of anorectal abscesses" } ] }, { "id": "pmid:7231748", "pmid": "7231748", "doi": null, "nctId": null, "pmcid": null, "title": "Peri-anal abscess--the relationship between peri-anal abscess, hepatitis B and sexual behavior", "firstAuthor": "Van Baal", "multipleAuthors": true, "journal": "Neth J Surg", "year": 1981, "design": "case-series", "n": 22, "nField": "reported", "population": "patients with abscess or fistula around the anus", "intervention": "testing for hepatitis B markers (HBsAg and anti-HBs)", "comparator": "no comparator", "primaryOutcome": "presence of hepatitis B virus markers and link to sexual behavior", "result": "positive hepatitis B markers found only in male patients who reported frequent homosexual contact", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a very small, uncontrolled observational study that does not test any method of preventing fistula formation.", "directness": "indirect", "relevanceNote": "", "limitations": "Small sample size, no control group, selective testing, and no assessment of fistula prevention methods.", "followUp": "", "plainFinding": "Does not address fistula prevention.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/7231748/", "sourceText": "Twenty-two patients with a peri-anal abscess or peri-anal fistula were studied selectively for the presence of HBsAg and anti-HBs. In 14 male and 8 female patients studied, the incidence of anti-HBs was 6 and of HBsAg 1. Positive findings occurred only in European male patients who invariably showed frequent homosexual contacts. It is concluded that, in homosexual patients with peri-anal abscess, the presence of HBsAg and anti-HBs should be determined as a matter of routine and all preventive measures should be taken for possible contamination with hepatitis B virus until proven negative.", "provenance": [ { "field": "population", "quote": "Twenty-two patients with a peri-anal abscess or peri-anal fistula were studied selectively for the presence of HBsAg and anti-HBs." }, { "field": "n", "quote": "Twenty-two patients with a peri-anal abscess or peri-anal fistula were studied selectively" }, { "field": "intervention", "quote": "studied selectively for the presence of HBsAg and anti-HBs" }, { "field": "comparator", "quote": "In 14 male and 8 female patients studied, the incidence of anti-HBs was 6 and of HBsAg 1." }, { "field": "primaryOutcome", "quote": "the incidence of anti-HBs was 6 and of HBsAg 1" }, { "field": "result", "quote": "Positive findings occurred only in European male patients who invariably showed frequent homosexual contacts." } ] }, { "id": "pmid:7376345", "pmid": "7376345", "doi": null, "nctId": null, "pmcid": null, "title": "[Pathogenesis of postoperative complications of paraproctitis and measures for their prevention]", "firstAuthor": "Nazarov", "multipleAuthors": true, "journal": "Vestn Khir Im I I Grek", "year": 1980, "design": "case-series", "n": null, "nField": "not-reported", "population": "people having surgery for acute paraproctitis (anal gland abscess)", "intervention": "removing or treating the inflamed anal crypts (cryptotomy/cryptectomy) during the surgery", "comparator": "no specific comparison group described", "primaryOutcome": "postoperative complications such as abscess recurrence or anal fistula", "result": "treating the crypts during surgery reduced local complications and was seen as a way to prevent recurrent abscesses or fistulas", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is an old descriptive report without a clear control group or defined patient numbers, so it can't reliably prove cause and effect", "directness": "direct", "relevanceNote": "", "limitations": "no total patient count given, no comparison group described, and no study design details provided", "followUp": "", "plainFinding": "Treating anal crypts may prevent fistulas.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/7376345/", "sourceText": "The inflammation of Morgagni crypts in the anal canal plays a great part in pathogenesis of acute paraproctitis and anal fistula. Such inflammation is often of diffuse character and in 18--19% of cases results in postoperative complications--acute and chronic cryptitis and subcutaneous microabscesses. Sanitation of Morgagni crypts (cryptotomy and cryptectomy) during radical operations for paraproctitis decreases the number of local postoperative complications and may be considered as one of the prophylactic measures against recurrent abscesses or anal fistulas.", "provenance": [ { "field": "population", "quote": "radical operations for paraproctitis" }, { "field": "intervention", "quote": "Sanitation of Morgagni crypts (cryptotomy and cryptectomy) during radical operations for paraproctitis" }, { "field": "comparator", "quote": "decreases the number of local postoperative complications" }, { "field": "primaryOutcome", "quote": "postoperative complications--acute and chronic cryptitis and subcutaneous microabscesses" }, { "field": "result", "quote": "decreases the number of local postoperative complications and may be considered as one of the prophylactic measures against recurrent abscesses or anal fistulas" } ] } ], "faqs": [ { "q": "How can I prevent fistula recurrence?", "a": "If a fistula tract is already visible when the abscess is drained, treating it at the same time - for example with a seton - lowered recurrence in a randomised trial and a review of similar trials, compared with draining the abscess alone. If a fistula has already formed and been treated once, no study here specifically tested how to stop it coming back a second time." }, { "q": "How do I prevent a fistula after an abscess?", "a": "No single method reliably prevents this in every case. The clearest evidence relates to surgery itself: if a fistula tract is seen while draining the abscess, treating it then may lower later problems. Antibiotics are not a reliable answer - trials disagree, and the best-designed one found antibiotics were linked to more fistulas, not fewer." }, { "q": "Should I take antibiotics after my abscess is drained to stop a fistula forming?", "a": "Don't assume antibiotics will prevent a fistula. One well-conducted, placebo-controlled trial found antibiotics were linked to more fistulas forming, not fewer, while a different trial found the opposite. Talk to your surgeon about whether antibiotics are needed for your infection generally, rather than taking them specifically to prevent a fistula." }, { "q": "What should I do instead to lower my risk?", "a": "Ask your surgeon to check for a fistula tract at the time of your abscess drainage. If one is found, treating it in the same operation - for example with a seton - has the most consistent evidence for lowering the chance of it coming back, without a clear rise in bowel control problems in these trials." }, { "q": "Does packing the wound help prevent a fistula?", "a": "No. A randomised trial found packing the wound after drainage made no significant difference to fistula or recurrence rates, and caused more pain than leaving it unpacked." } ], "searchedAs": [ "how to prevent fistula", "how to prevent anal fistula", "how to avoid fistula", "how to prevent a fistula from forming", "how to prevent fistula in ano", "how to prevent fistula recurrence", "how to prevent fistula after abscess" ], "patientTakeaway": "There is no proven way to guarantee a fistula won't form after an abscess is drained - it happens in a meaningful share of people regardless of what is done. Don't take antibiotics specifically to prevent one: the strongest trial found they did not help and may have been linked to more fistulas. Ask your surgeon whether a fistula tract is visible during your drainage procedure, because treating it then, in the same operation, has the best evidence for lowering the chance of problems coming back.", "methodology": { "databases": [ "PubMed", "ClinicalTrials.gov", "Crossref" ], "searchStrings": { "pubmed": "(\"Rectal Fistula/prevention and control\"[Mesh] OR \"anal fistula\"[tiab] OR \"fistula in ano\"[tiab] OR \"fistula-in-ano\"[tiab]) AND (\"Abscess\"[Mesh] OR \"anorectal abscess\"[tiab] OR \"perianal abscess\"[tiab] OR \"perirectal abscess\"[tiab]) AND (prevent*[tiab] OR prophylax*[tiab] OR recurrence[tiab])" }, "pubmedQueryTranslation": "(\"rectal fistula/prevention and control\"[MeSH Terms] OR \"anal fistula\"[Title/Abstract] OR \"fistula-in-ano\"[Title/Abstract] OR \"fistula-in-ano\"[Title/Abstract]) AND (\"Abscess\"[MeSH Terms] OR \"anorectal abscess\"[Title/Abstract] OR \"perianal abscess\"[Title/Abstract] OR \"perirectal abscess\"[Title/Abstract]) AND (\"prevent*\"[Title/Abstract] OR \"prophylax*\"[Title/Abstract] OR \"recurrence\"[Title/Abstract])", "searchedOn": "2026-10-13", "inclusion": [ "Human, animal or laboratory studies reporting an outcome relevant to the question" ], "exclusion": [ "Records about a different condition or intervention", "Records reporting no outcome", "Retracted publications, which are listed but excluded from every count" ], "extractionLevel": "abstract", "gradingNote": "Evidence strength is adapted from the GRADE framework. It is not a GRADE assessment and was not produced by a GRADE panel.", "limits": [ "Fields were read from abstracts, not full text, so detail reported only in a paper's methods section is not captured." ] }, "seo": { "title": "How to Prevent an Anal Fistula After Abscess Drainage", "description": "6 randomised trials on preventing fistula after abscess drainage disagree - one found antibiotics raised the risk instead of lowering it." }, "lastChecked": "2026-10-13", "lastChanged": "2026-10-13", "nextCheckDue": "2026-11-13", "history": [], "pipeline": { "screenModel": "claude-haiku-4-5", "extractModel": "claude-sonnet-5", "composeModel": "claude-sonnet-5", "promptVersion": "ev-1", "ranOn": "2026-10-13", "gradeRules": "ev-1" }, "status": "published" }