Reviewing perianal abscess management and recurrence: lessons from a trainee perspective

Abstract

Background Perianal abscesses are a common surgical emergency. Due to their perceived ease, drainage is often delegated to junior trainees with varying levels of experience. The purpose of this study is to evaluate the current trend in perianal abscesses management at our institution, and identify factors that predict subsequent fistula formation or abscess recurrence. Methods All acute patients admitted to a major teaching hospital who required surgical drainage of a perianal abscess were analysed over a two‐year period from January 2019 to December 2020. Patient demographics, clinical and laboratory findings were retrospectively reviewed. Proceduralist experience, operative management strategy and recurrence rates (fistula or abscess) were analysed. Results The mean age of patients was 43 years old, and 73% were male. Trainees performed 96% of the procedures. Re‐presentation with a fistula or abscess recurrence requiring further surgery was 31%. Comorbidities of IBD, diabetes, or malignancy were present in one‐third of patients and significantly increased the risk of recurrence (P = 0.01). Searching for a fistula tract was performed in 41% of cases but did not reduce recurrence (P = 0.9). Seton insertion occurred in 10%, and fistulotomy in 2%. Conclusion Perianal abscess drainage at our institution is almost exclusively performed by trainees, the majority of which occurs after‐hours. Patients who present with a fever, inflammatory bowel disease, diabetes mellitus or malignancy are at an increased risk of recurrent abscess or a subsequent fistula after drainage, and input from an experienced surgeon may be of value when considering seton insertion or fistulotomy.

Anorectal Abscess

“…67 68 Additionally, many abscess drainage procedures are done by trainees and surgeons without specific colorectal training, and so one viewpoint is that they should be kept as simple as possible to avoid iatrogenic injury. 69 70 In the largest series of 1,000 patients where primary fistulotomy was performed, 7% of patients endorsed short-term changes in anal function and 3.2% at 2 years. 71 Smaller studies also support this finding.…”

Purulent Skin and Soft Tissue Infections, Challenging the Practice of Incision and Drainage: A Scoping Review

“…A 75% empirical success rate of the traditional incision and drainage procedure in the resolution of SSTI infection was accepted based on the median historic and contemporary evidence [18,19,68,72]. Taking the median percentile, where available across the relative studies, the empirical efciency of each SSTI management option can be ranked as follows:…”

“…Te driving premise is ofered that the formulaic familiarity with this surgical dogma has blinded clinicians and nurses to the intervention's progressive failure. Te efcacy of incision and drainage has been exclusively justifed by the narrow scope of empirical infective resolution [18]. While this without doubt should be accepted as an essential outcome for any SSTI intervention, the efciency of incision and drainage continues to wane [18,19], likely secondary to the epidemic rise of CA-MRSA [14,15].…”

“…Te efcacy of incision and drainage has been exclusively justifed by the narrow scope of empirical infective resolution [18]. While this without doubt should be accepted as an essential outcome for any SSTI intervention, the efciency of incision and drainage continues to wane [18,19], likely secondary to the epidemic rise of CA-MRSA [14,15]. Since 2010, there has been a concern that the technique is no longer sufcient within the contemporary treatment population [20].…”

Study on the factors influencing the prognosis after perianal abscess surgery

“…In addition, perianal abscesses may also be caused by Crohn’s disease, sweat gland infection, human immunodeficiency virus, radiation therapy and skin infection [ 4 – 6 ]. The location of the abscess cavity is classified as perianal, ischioanal, intersphincteric and supralevator [ 7 ]. If it cannot be treated in time, it will usually cause the abscess to increase in volume or even rupture, so the pus cannot be discharged completely, leading to the recurrence of the perianal abscess [ 8 ].…”