The Initial Approach to Anorectal Abscesses: Fistulotomy Is Safe and Reduces the Chance of Recurrences

Abstract

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.

Fistula in ano: anatomoclinical aspects, surgical therapy and results in 844 patients

“…Anorectal manometry is not widely used but is advised by some authors prior to fistula surgery [13,19,20]. In case of deficient preoperative sphincter function, even in patients with perfect continence, the decision to divide the sphincter must be evaluated with caution.…”

German S3 guideline: anal abscess

“…In subanodermal or intersphincteric anal abscesses, fistulas are rare and predominantly superficial, but the rate of complex fistulas is distinctly higher in ischioanal and supralevator abscesses [10]. Incidence depends on the abscess type and can reach 40% in ischioanal and supralevator abscesses [26,28,36,37]. Therefore, extensive fistula exploration is not recommended in the initial procedure.…”

Fistula in ano in infants: who recurs?

“…Treatment has historically been with fistulotomy when the fistula is found or incision and drainage without identification of the fistula [4]. Some authors have advocated diligent search for the fistulous tract [5] while others believe that excessive probing may result in iatrogenic fistula formation [4]. Recently, some investigators have suggested that conservative management of PAAs results in a lower fistula rate than with operative intervention [6].…”