*Michał Puliński1, Natalia Hawryluk2, Wojciech Choiński1
Analysis of treatment methods and outcomes for perianal abscess (PA) and fistula in ano (FIA) in infants
Analiza metod i wyników leczenia ropni okołoodbytniczych i przetok okołoodbytniczych u niemowląt
1Clinical Department of Paediatric Surgery and Urology, Department of Surgery, School of Public Health, University of Warmia and Mazury in Olsztyn
2Students’ Paediatric Surgery Science Club, Department of Surgery, Collegium Medicum, University of Warmia and Mazury in Olsztyn
Wstęp. Ropień okołoodbytniczy (PA) u dzieci jest dość powszechnym schorzeniem i występuje od 0,5 do 4,3% w populacji niemowląt. W większości przypadków ma on związek z przetoką okołoodbytniczą (FIA). Leczeniem chirurgicznym FIA są: fistulektomia, fistulotomia lub rzadko kryptotomia.
Cel pracy. Celem pracy jest retrospektywna analiza metod i wyników leczenia PA i FIA u niemowląt w Klinicznym Oddziale Chirurgii i Urologii Dziecięcej WSSzD w Olsztynie w latach 2014-2019.
Materiał i metody. Od stycznia 2014 do grudnia 2019 roku leczono 44 niemowląt z rozpoznaniem PA i FIA. Większość pacjentów stanowili chłopcy – 41 (93%) i tylko 3 (7%) dziewczynki. W przypadku PA stosowano trzy różne metody leczenia: nacięcie i drenaż, fistulotomię lub fistulektomię.
Wyniki. Z grupy 44 leczonych niemowląt z rozpoznanym PA i FIA 29 leczono tylko poprzez nacięcie i drenaż. U 19 z nich uzyskano wyleczenie. U 9 pacjentów zidentyfikowano FIA i wykonano fistulektomię lub fistulotomię. W tej grupie był jeden nawrót, który ponownie leczono poprzez fistulektomię i uzyskano wyleczenie. U 6 pacjentów PA opróżnił się samoistnie, z czego u 3 pacjentów nastąpił nawrót i w trakcie kolejnego pobytu w szpitalu rozpoznano FIA. Wykonano 7 fistulotomii oraz 14 fistulektomii, a ich skuteczność wyniosła odpowiednio 100 vs 93%.
Wnioski. W przypadku rozpoznania przetoki okołoodbytniczej u niemowlęcia najskuteczniejszą i najbezpieczniejszą metodą leczenia jest fistulotomia.
W każdym przypadku rozpoznania ropnia okołoodbytniczego należy poszukać przetoki okołoodbytniczej.
Introduction. Perianal abscess (PA) is a relatively common condition in children and occurs in 0.5 to 4.3% of the infant population. In the majority of cases, it is associated with fistula in ano (FIA). Surgical treatment of FIA includes fistulectomy, fistulotomy or, rarely, cryptotomy.
Aim. The aim of the study is to perform a retrospective analysis of treatment methods and outcomes for PA and FIA in infants at the Department of Paediatric Surgery and Urology of the Regional Specialised Children’s Hospital in Olsztyn, Poland, in 2014-2019.
Material and methods. From January 2014 to December 2019, 44 infants with diagnosed PA and FIA were treated. The majority of patients were boys: 41 (93%) and only 3 (7%) were girls. For PA, three different treatment methods were used: incision and drainage, fistulotomy or fistulectomy.
Results. Out of 44 treated infants with diagnosed PA and FIA, 29 were treated only by incision and drainage. Among them, 19 were cured. FIA was identified in 9 patients and fistulectomy or fistulotomy was performed. In this group, there was 1 recurrence, which was retreated with fistulectomy and cured. In 6 patients, PA drained spontaneously; in 3 of them there was recurrence and FIA was diagnosed during another hospital stay. There were 7 fistulotomies and 14 fistulectomies performed and their efficacy was 100 vs 93%, respectively.
Conclusions. Fistulotomy is the most effective and safest method of FIA treatment in infants.
In every case of perianal abscess diagnosis, a fistula in ano should be looked for.
Perianal abscess (PA) is a relatively common condition in children and occurs in 0.5 to 4.3% of the infant population (1).
In the majority of cases it is associated with fistula in ano (FIA) (2). According to the literature, FIA occurs in 20 to 85% of infants with PA, with a clear predominance of boys (2). The aetiology of PA and FIA is unclear, but there are two theories: congenital and acquired. According to the former one, fistulae originate from deeper crypts of Morgagni. A larger crypt depth than normal (1-2 mm) facilitates colonisation and bacterial entrapment in the crypt. Bacteria induce inflammation and the subsequent development of PA and, consequently, FIA in the majority of cases. This abnormal crypt structure may be caused by an imbalance of androgens and oestrogens in the foetus. According to the theory of acquired aetiology, secondary crypt infection is caused by excessive androgen stimulation of sebaceous glands. This results in a higher prevalence of PA in boys. PA may be a symptom of Crohn’s disease, ulcerative colitis, tuberculosis or immune disorders (2). The majority of PA in infants reported in this study are low fistulae, unlike in adults, in whom high fistulae predominate.
PA treatment consists mainly in incision and drainage. Unfortunately, this treatment method is associated with a high rate of recurrence. For this reason, according to many authors, PA should be treated as radically as FIA. Surgical treatment of FIA includes fistulectomy (fistula excision), fistulotomy (fistula incision) or, less commonly, cryptotomy (crypt incision) (3-5). The first stage of surgical treatment consists in identifying the fistula or incising the perianal abscess and visualising the fistula and then splinting it with a metal probe, as presented in figure 1.
Fig. 1. Splinting of the fistula using a probe
In fistulectomy, after the whole fistula is visualised, the skin above it is incised with a scalpel along the fistula’s whole length and then the fistula is completely excised with an electric knife. In fistulotomy, after the fistula is visualised using a probe, it is transected together with the skin with an electric knife using a single cut, which is presented in figure 2.
Fig. 2. Fistula transection with an electric knife (fistulotomy)
Upon fistula transection and probe removal, the lumen of the fistula is gently coagulated using a monopolar device (if necessary). In both fistulectomy and fistulotomy, the wound is not sutured and heals by granulation, which is shown in figure 3.
Fig. 3. Status post fistulotomy
This operation is performed in children in an operating theatre under general anaesthesia.
The aim of the study is to perform a retrospective analysis of treatment methods and outcomes for PA and FIA in infants at the Department of Paediatric Surgery and Urology of the Regional Specialised Children’s Hospital in Olsztyn, Poland, in 2014-2019.
Material and methods
A retrospective analysis was performed of medical records of 44 children with diagnosed PA and FIA treated from January 2014 to December 2019 at the Department of Paediatric Surgery and Urology of the Regional Specialised Children’s Hospital in Olsztyn, Poland. All of the analysed children were referred for surgical treatment with a diagnosis of PA. The age of the treated children was from 1 month to 12 months (mean 3.58 months of age, median 2 months of age). The age structure of the treated children is presented in figure 4.
Fig. 4. Age structure of the treated children
The largest group were children aged up to 2 months. The mean age of children at the time of the operation was 4.16 months. The vast majority of patients were boys: 41 (93%) and only 3 (7%) were girls. Upon admission, a single abscess was found in 19 children and 2 concurrent abscesses were found in 3 children. In 21 patients a single fistula was diagnosed and in 1 patient two fistulae were found at the same time. Out of all FIA, 10 penetrated towards a crypt and in 1 female patient FIA penetrated towards the right labium majorum. There were 17 PA and FIA on the right buttock and 10 on the left buttock. No exact location was provided for 17 patients. Figure 5 presents the location of PA and FIA in the analysed infants in relation to the clock dial.
Fig. 5. Location of PA and FIA in relation to the anus in the analysed infants
The analysis included medical data such as age at surgery, sex, location of the lesion, type of treatment applied, recurrence and time from the primary lesion to recurrence. For PA, three different methods of treatment were used: incision and drainage, fistulotomy and fistulectomy; for FIA, fistulotomy or fistulectomy were performed. After the operation, every day during the change of dressing Microdacyn [translator’s note: sodium hypochlorite, hypochlorous acid] or Octenisept [translator’s note: octenidin dichydrochloride, phenoxyethanol] solutions were used to wash the wound. Subsequently, 1% neomycin ointment was used under the dressing.
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