Surgical management of perianal abscess in neonates and infants

Abstract

BackgroundThe optimal management of perianal abscess in neonates and infants remains unclear, including the need for laying open of the fistula and the role of microscopy and culture studies (MCS). We aimed to report the recurrence rate following incision and drainage alone (I&D) compared to incision and drainage with laying open of the fistula (I&DF) and to determine the value of MCS in perianal abscess management.MethodsFollowing ethical approval (16326Q), a 10‐year (2007–2017) review of children younger than 1 year presenting with a perianal abscess was performed. Presence of a fistula was sought in all patients. Data are presented as number of cases (%), median (range) and analysed using Fisher's exact test and Mann–Whitney U‐test. P‐values of <0.05 were considered significant.ResultsWe identified 108 patients (107 (99.1%) males) with 111 abscesses (three bilateral); 26 in I&D group and 85 in I&DF group. Initial abscess occurred to the right of midline in 64 cases (58%) and to the left of midline in 47 cases (42%). Twenty‐two (20%) recurred after 30 (6–372) days. Sixty‐five (59%) had MCS performed. Recurrence was higher in I&D group (9/26) versus I&DF group (13/85) (P = 0.04 (relative risk 2.2, 95% confidence interval 1.0–4.5)). There was no difference in recurrence within each group between patients with or without MCS (I&D group, P = 0.1; I&DF group, P = 0.3).ConclusionThe recurrence of surgically managed perianal abscess is lower when a fistula is identified and laid open at the initial operation. There is little value of MCS in the management of paediatric perianal abscess.

Incision and Drainage With Primary Fistulotomy of Perianal Abscess Is Safe and Effective in Neonates: A Long-Term Follow-Up Study

“…The rate of fistula (between the PA and the anal crypt) identified at the time of primary drainage varies widely in different studies. The percentage of communication between the PA and the internal (anal) opening was <20% (1,4,6,7,11) or more than 60% (25,27,(29)(30)(31)(32). Our results (approximately 80%) support the latter.…”

“…Our findings are supported by several studies. There were no recurrences (26,27,31) or the recurrence rate was <15% (29,30,32) in patients who underwent fistulotomy at the time of ID. These findings are in excellent agreement with ours.…”

“…Unfortunately, some studies did not distinguish between them (1-3, 11, 14, 18, 29-34). Of those studies, the rate of fistula formation or recurrence after ID varies widely, which was <20% in 2 studies (2,3), between 20 and 50% in 7 studies (1,18,(29)(30)(31)(32)34), and more than 50% in 2 studies (14,33). Altogether, previous studies differed substantially regarding the rate of fistula formation or recurrence after ID.…”

“…However, in the past two decades, some studies have shown that the conservative management appears to be effective in selected cases (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23). On the other hand, the other studies have recommended that the surgical procedure should involve a careful identification for the fistula and treatment of that by fistulotomy (24)(25)(26)(27)(28)(29)(30)(31)(32). Thus, at present, the optimal management has not yet been established.…”

Treatment of Perianal Abscess and Fistula in Infants and Young Children: From Basic Etiology to Clinical Features

“…A recent study also showed that the recurrence rates of incision drainage and fistulotomy were 34.6% and 15.3%, respectively, and the difference was significant (P = .04). 35 However, some studies have reported that after fistulectomy in adults, the recurrence rate of anal fistula is 16%-70%, and the incontinence rate is between 0% and 40%. 36 Compared with adults, infantile fistula is lower in position, shorter in length, and involves less of the sphincter, which can be easily found during the operation.…”