*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
Streszczenie
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.
Summary
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.
Introduction
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.
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
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
Powyżej zamieściliśmy fragment artykułu, do którego możesz uzyskać pełny dostęp.
Mam kod dostępu
- Aby uzyskać płatny dostęp do pełnej treści powyższego artykułu albo wszystkich artykułów (w zależności od wybranej opcji), należy wprowadzić kod.
- Wprowadzając kod, akceptują Państwo treść Regulaminu oraz potwierdzają zapoznanie się z nim.
- Aby kupić kod proszę skorzystać z jednej z poniższych opcji.
Opcja #1
29 zł
Wybieram
- dostęp do tego artykułu
- dostęp na 7 dni
uzyskany kod musi być wprowadzony na stronie artykułu, do którego został wykupiony
Opcja #2
69 zł
Wybieram
- dostęp do tego i pozostałych ponad 7000 artykułów
- dostęp na 30 dni
- najpopularniejsza opcja
Opcja #3
129 zł
Wybieram
- dostęp do tego i pozostałych ponad 7000 artykułów
- dostęp na 90 dni
- oszczędzasz 78 zł
Piśmiennictwo
1. Festen C, van Harten H: Perianal abscess and fistula-in-ano in infants. J Pediatr Surg 1998; 33: 711-713.
2. Emile SH, Elfeki H, Abdelnaby M: A systematic review of the management of anal fisula in infants. Tech Coloproctol 2016; 20: 735-744.
3. Afşarlar CE, Karaman A, Tanır G et al.: Perianal abscess and fistula-in-ano in children: clinical characteristic, management and outcome. Pediatr Surg Int 2011; 27: 1063-1068.
4. Novotny NM, Mann MJ, Rescorla FJ: Fistula in ano in infants: who recurs? Pediatr Surg Int 2008; 24: 1197-1199.
5. Karlsson AJ, Salö M, Stenström P: Outcomes of Various Interventions for First-Time Perianal Abscesses in Children. Biomed Res Int 2016; 9712854.
6. Serour F, Somekh E, Gorenstein A: Perianal abscess and fistula-in-ano in infants: a different entity? Dis Colon Rectum 2005; 48: 359-364.
7. Carmona J, Osterman A, Lugo-Vicente H: Fistula-in-ano in children: a case series. Bol Assoc Med P R 2011; 103: 14-17.
8. Basaranoglua ST, Ozsurekcia Y, Cengiza AB et al.: Absceso perianal en niños: perspectiva desde el campo de la infectología pediátrica. An Pediatr (Barc) 2019; 90: 370-375.
9. Chang HK, Ryu JG, Oh JT: Clinical characteristics and treatment of perianal abscess and fistula-in-ano in infants. J Pediatr Surg 2010; 45: 1832-1936.
10. Fitzgerald RJ, Harding B, Ryan W: Fistula-in-ano in childhood: a congenital etiology. J Pediatr Surg 1985; 20: 80-81.
11. Shafer AD, McGlone TP, Flanagan RA: Abnormal crypts of Morgagni: The cause of perianal abscess and fistula-in-ano. J Pediatr Surg 1987; 22: 203-204.
12. Murthi GV, Okoye BO, Spicer RD et al.: Perianal abscess in childhood. Pediatr Surg Int 2002; 18: 689-691.
13. Lunniss PJ, Jenkins PJ, Besser GM et al.: Gender differences in incidence of idiopathic fistula in-ano are not explained by circulating sex hormone. Int J Colorectal 1995; 10: 25-28.
14. Medscape: pediatric fistula-in-ano (database on the internet); http://emedicine.medscape.com/article/935312-overview#a7 (data dostępu: 20.10.2015).
15. Gong Z, Han M, Wu Y et al.: Treatment of First-Time Perianal Abscess in Childhood, Balance Recurrence and Fistula Formation Rate with Medical Intervention. Eur J Pediatr Surg 2018; 28: 373-377.
16. Niyogi A, Agarwal T, Broadhurst J, Abel RM: Management of perianal abscess and fistula-in-ano in children. Eur J Pediatr Surg 2010; 20: 35-39.
17. Poenaru D, Yazbeck S: Anal fistula in infants: etiology, features, management. J Pediatr Surg 1993; 28: 1194-1195.
18. Gafar A: Fistulotomy versus fistulectomy as a treatment for low anal fistula in infants: a comparative study. Ann Pediatr Surg 2013; 9: 103-107.
19. Nelson R: Anorectal abscess fistula: what do we know? Surg Clin North Am 2002; 82: 1139-1151.
20. Inoue M, Sugito K, Ikeda T et al.: Long-Term Results of Seton Placement for Fistula-in-ano in Infants. J Gastrointest Surg 2014; 18: 580-583.
