Supralevator abscess

Abstract

Anorectal suppurations are quite common. Supralevator abscesses, previously regarded as a rare subgroup, were seen in 9.1 per cent of 506 patients admitted to Cook County Hospital in a two-year period. Aggressive supportive management was followed by early, adequate drainage through the rectum whenever indicated. When fistulas were identified, either a primary fistulotomy or a two-stage fistulotomy using a seton was performed in the majority of cases. Important factors in the prevention of morbidity and mortality included debridement of all necrotic tissue, careful bacteriologic studies and judicious use of antibiotics, close postoperative observation, and long-term follow-up of the patients.

The space between: a supralevator abscess caused by perforated diverticulitis

“…Drainage of a supralevator collection poses more challenge than other types of anorectal abscesses [2]. These collections lie within a closed potential space between the pelvic floor (peritoneal reflection) and the levator ani muscles, lateral to the walls of the rectum [8], making adequate drainage via a transrectal approach difficult, with high recurrence rates.…”

“…These collections lie within a closed potential space between the pelvic floor (peritoneal reflection) and the levator ani muscles, lateral to the walls of the rectum [8], making adequate drainage via a transrectal approach difficult, with high recurrence rates. Concomitant ischiorectal drainage may result in a complex fistula that can be difficult to manage [2]. Although percutaneous, trans-sciatic drainage of a supralevator collection could result in outward spread along the lateral fascial planes of the ischiorectum (as in this case), the anatomical boundaries of this closed space make the reverse scenario unlikely; a primary ischiorectal collection would be drained superficial to the supralevator space, never entering it, while deep to the supralevator space lies the lateral wall of the rectum itself, making internal catheter drainage especially challenging.…”

“…Out of the documented regions in which this disease is known to exist (perianal, intersphincteric, ischiorectal, submucosal and supralevator) [1] supralevator abscesses account for only 3–4% of total disease incidence [2, 3]. Risk factors for the development of abscesses in this location include male gender, obesity, diabetes, immunodeficiency, malignancy, foreign bodies, tuberculosis, trauma and inflammatory bowel disease [3–6].…”

“…Risk factors for the development of abscesses in this location include male gender, obesity, diabetes, immunodeficiency, malignancy, foreign bodies, tuberculosis, trauma and inflammatory bowel disease [3–6]. Although few, they are most severe in their clinical course and consequence, with perianal sepsis often necessitating surgical intervention due to inadequate initial drainage [2]. We report the unique presentation of a supralevator abscess with extension into the ischiorectal fossa secondary to perforated diverticulitis, with emergent surgery required after unsuccessful percutaneous drainage.…”

Successful Management of a Recurrent Supralevator Abscess: A Case Report

“…The intensive surgical course of this patient highlights the difficult nature of this disease. Although the supralevator abscess is rare [7], it requires much more aggressive treatment than other locations of Anorectal abscesses. Drainage can be attempted through many approaches.…”