Spiral.imperial.ac.uk



Persistent fistula following anorectal abscess drainage – local experience of 11 yearsKapil Sahnan, Alan Askari, Samuel O Adegbola, Janindra Warusavitarne, Phillip FC Lung, Ailsa L Hart, Omar D Faiz, Robin K.S Phillips, Phillip J TozerRunning head:Fistula formation following abscess Category: Original article (d. Anorectal Disease)Corresponding Author: Kapil Sahnan, Department of Colorectal Surgery, St Mark’s Hospital, London, HA1 3UJks303@.uk (+44 7725 810 141) @KSahnan @alan_askari @colorectal_jay @pfclung @DrAilsaHart @OmarFaiz_SETOC @philtozer1 @StMarksFRU @StMarksHospitalWord Count: Main text (2,031) and Abstract (274)Author Contributions: All authors have contributed to this manuscriptKeywords:Abscess, fistula, IBDPrevious Presentation:Sahnan K, Askari A, Adegbola SO, Tozer PJ, Oke S, Watfah J, Lung PFC, Hart AL, Faiz OD, Phillips RKS. Rate of fistula formation after an anorectal abscess. ACPGBI, Bournemouth. Oral Presentation, July 2017Sahnan K, Askari A, Adegbola S, Tozer P, Hart A, Phillips R, Faiz O. Prediction of fistula formation following a Crohn’s abscess. ESCP, Poster Presentation, September 2017Sahnan K, Askari A, Adegbola S, Tozer P, Lung P, Watfah J, Warusavitarne J, Faiz O, Hart A, Phillips R. Abscess to fistula formation – local experience of 11 years. ESCP, Poster Presentation, September 2017AffiliationsAuthor Titles:Mr. Kapil Sahnan BSc (Hons), MBBS, MRCS – Clinical Research Fellow1,2Mr. Alan Askari MB ChB, MRCS – Clinical Research Fellow2Mr. Samuel O Adegbola BSc (Hons), MBBS, MRCS – Clinical Research Fellow1, 2Mr. Janindra Warusavitarne B Med FRACS PhD – Consultant Colorectal Surgeon, Honorary Senior Clinical Lecturer1, 2Dr. Phillip FC Lung BSc (Hons) MBBS MRCS, FRCR - Consultant Gastrointestinal radiologist1,2Prof Ailsa Hart BA (Hons) BMBCh FRCP PhD– Consultant Gastroenterologist, Professor of Practice 1,2Mr. Omar Faiz BSc (Hons), MBBS, FRCS, MS – Consultant Colorectal Surgeon, Honorary Senior Clinical Lecturer1, 2,Prof Robin K.S Phillips FRCS, MS - Professor of Colorectal Surgery1,2Mr. Phil Tozer FRCS, MD (res), Consultant Surgeon, Honorary Research Fellow1,2Author Institutions:Fistula Research Unit, St Mark’s Hospital & Academic Institute, Harrow, Middlesex, HA1 3UJ, United KingdomDepartment of Surgery and Cancer, Imperial College, St Mary’s Hospital, Praed Street, London W21NY, United Kingdom.Funding & Disclosures: Kapil Sahnan is supported by a Royal College of Surgeons of England Research Scholarship. The other authors have no conflict of interests or financial ties to disclose.Acknowledgments: Stephen Hiles, Senior Information Analyst, Research & Development Dept. Northwick Park Hospital Abstract (a video version will be created if the manuscript is accepted)Background: The characteristics of patients who develop a fistula-in-ano following a anorectal abscess are unclear.Objective: Our study explores this relationship and patient factors associated with fistula development. Design: ICD-10 (International Classification of Disease, 10th revision) and OPCS (Classification of Interventions and Procedures, version 4) codes were used to identify all patients with a primary anorectal abscess. Multivariable analysis was used to identify factors predictive of fistula formation.Settings: The study was conducted in a district general hospital Patients: Patients with anorectal abscess who admitted to our institution (2004-2015).Main Outcome Measures: The rate of subsequent fistula formation. Results: A total of 1,970 abscess patients were identified; 70.0% (n=1,379) were male and 7.3% (n=144) had Crohn’s Disease. Fistulas occurred in 16.2% (n=319) at a median of 7 months (IQR 3-7). Patients with Crohn’s Disease were more than twice as likely to develop a fistula than non- Crohn’s Disease patients (32.6% vs. 14.9%, OR 2.5, 95% CI: 1.7-3.7, p<0.001). Crohn’s patients with a fistula were more likely to be women (55.3% vs. 34.6%, p=0.007) and aged under 30 (51.1% vs. 24.3%, p<0.001) than non-Crohn’s patients with a fistula. At multivariable analysis of the entire cohort, male gender (OR 0.7, 95% CI: 0.5-0.9, p=0.005), and diabetes mellitus (OR 0.5, 95% CI 0.3-0.9, p=0.027) were associated with a reduced likelihood of developing a fistula following abscess formation.Limitations: The study was limited by its single-center scope, retrospective analysis and lack of an established definition for Crohn's disease. Conclusions: Abscesses are more common in men but progression to fistula is more likely in women. The rate of fistula progression in Crohn’s disease is twice that in non-Crohn’s patients. Identification of patients “at risk”, may help delineate those who will benefit from a more conservative surgical approach, enhanced follow up or investigation after abscess drainage. IntroductionSurgeons have long questioned which factors predict a persistent fistula after drainage of anorectal abscess. Bacteriology and the presence of an internal opening have been cited, but with inconsistent results.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0007-1323", "PMID" : "7104611", "abstract" : "One hundred and sixty-five patients presented in a 4-year period: 68 (41.2 per cent) had had previous anorectal sepsis and in 56 of these patients (82.3 per cent) the presenting sepsis was at the site of the previous abscess. The abscesses were drained and pus was sent for culture; any fistula, if found, was laid open. A second examination under anaesthesia was performed within 7--10 days if no fistula had been found. The pus from 114 patients grew bowel-derived organisms; 62 (54.4 per cent) fistulas were found. The pus from 34 patients grew skin-derived organisms but no fistula was demonstrated in this group. It is suggested that a second examination need only be performed if culture of the pus grows bowel-derived organisms: anorectal abscesses which grow skin-derived organisms are not associated with a fistula.", "author" : [ { "dropping-particle" : "", "family" : "Grace", "given" : "R H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Harper", "given" : "I A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Thompson", "given" : "R G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The British journal of surgery", "id" : "ITEM-1", "issue" : "7", "issued" : { "date-parts" : [ [ "1982", "7" ] ] }, "page" : "401-3", "title" : "Anorectal sepsis: microbiology in relation to fistula-in-ano.", "type" : "article-journal", "volume" : "69" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹", "plainTextFormattedCitation" : "1", "previouslyFormattedCitation" : "¹" }, "properties" : { }, "schema" : "" }1,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/ans.13630", "ISSN" : "14451433", "PMID" : "27226422", "abstract" : "BACKGROUND The detection of gut organisms in perianal abscesses has been postulated to suggest an underlying communication with the anal canal. However, recent studies appear to contradict this observation. The aim of this study is to determine the value of bacteriological studies in perianal abscesses. METHODS A retrospective study of all patients who have had a surgical drainage of their perianal abscesses with concomitant microbiological examination from January 2010 to December 2012 was performed. Patients with known underlying anal fistula, Crohn's disease or previous perianal operations were excluded. RESULTS A total of 164 patients, median age of 42.0\u2009years (range 8-87) comprising of 78.7% males formed the study group. Gut organisms were cultured in 143 (87.2%) samples while 12 (7.3%) demonstrated skin organisms and nine did not yield any bacterial growth (5.5%). Twenty-nine (17.7%) patients developed anal fistula and 34 (20.7%) patients had a recurrence of the perianal abscess. The median follow-up period was 1450 (14-2391) days. There was no significant association between the presence of gut organism and development of fistulas (odds ratio\u2009=\u20090.48; 95% confidence interval\u2009=\u20090.17-1.37) or recurrence of perianal abscess (odds ratio\u2009=\u20091.66; 95% confidence interval\u2009=\u20090.46-6.01). CONCLUSION Bacteriological culture in perianal abscess is not useful for predicting the development of anal fistula or abscess recurrence. Hence, there is no need to perform this investigation on a routine basis.", "author" : [ { "dropping-particle" : "", "family" : "Xu", "given" : "Roland W.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tan", "given" : "Ker-Kan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chong", "given" : "Choon-Seng", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "ANZ Journal of Surgery", "id" : "ITEM-1", "issue" : "10", "issued" : { "date-parts" : [ [ "2016", "10" ] ] }, "page" : "782-784", "title" : "Bacteriological study in perianal abscess is not useful and not cost-effective", "type" : "article-journal", "volume" : "86" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "²", "plainTextFormattedCitation" : "2", "previouslyFormattedCitation" : "²" }, "properties" : { }, "schema" : "" }2,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0012-3706", "PMID" : "8076487", "abstract" : "PURPOSE A study of 523 fistulas of cryptoglandular origin operated on between January 1985 and December 1991 at the Lehigh Valley Hospital was undertaken for the purpose of establishing whether the \"so-called\" simple fistula-in-ano has a favorable outcome. High transsphincteric fistulas with or without high blind tract, suprasphincteric, extrasphincteric, and horseshoe fistulas as well as fistulas associated with inflammatory bowel disease were excluded. METHODS Four-hundred sixty-one patients with anal fistulas classified as simple fistulas-in-ano (uncomplicated transsphincteric, low and high blind track intersphincteric) were studied retrospectively. There were 310 males and 151 females with an average age of 42 years and mean follow-up of 34 months. RESULTS Thirty (6.5 percent) patients developed recurrent fistulas: 16 (53.3 percent) because of missed internal openings at initial surgery, six (20 percent) attributed to missed secondary tracks, five (16.7 percent) because of premature fistulotomy wound closure, and three (10 percent) because of miscellaneous factors. CONCLUSION All so-called simple fistulas-in-ano may not have readily detectable primary openings and may possess secondary tracks which preclude their behavior as simple fistulas.", "author" : [ { "dropping-particle" : "", "family" : "Sangwan", "given" : "Y P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rosen", "given" : "L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Riether", "given" : "R D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stasik", "given" : "J J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sheets", "given" : "J A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Khubchandani", "given" : "I T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Diseases of the colon and rectum", "id" : "ITEM-1", "issue" : "9", "issued" : { "date-parts" : [ [ "1994", "9" ] ] }, "page" : "885-9", "title" : "Is simple fistula-in-ano simple?", "type" : "article-journal", "volume" : "37" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "³", "plainTextFormattedCitation" : "3", "previouslyFormattedCitation" : "³" }, "properties" : { }, "schema" : "" }3 A recent population database study found that 17.2% (27,349 of 158,713) of patients who present with an anorectal abscess will subsequently present with a fistula. This rate rose to nearly one in two amongst patients with Crohn’s disease.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/bjs.10614", "ISSN" : "00071323", "PMID" : "28857130", "abstract" : "BACKGROUND Progression from anorectal abscess to fistula is poorly described and it remains unclear which patients develop a fistula following an abscess. The aim was to assess the burden of anorectal abscess and to identify risk factors for subsequent fistula formation. METHODS The Hospital Episode Statistics database was used to identify all patients presenting with new anorectal abscesses. Cox regression analysis was undertaken to identify factors predictive of fistula formation. RESULTS A total of 165\u2009536 patients were identified in the database as having attended a hospital in England with an abscess for the first time between 1997 and 2012. Of these, 158\u2009713 (95\u00b79 per cent) had complete data for all variables and were included in this study, the remaining 6823 (4\u00b71 per cent) with incomplete data were excluded from the study. The overall incidence rate of abscess was 20\u00b72 per 100\u2009000. The rate of subsequent fistula formation following an abscess was 15\u00b75 per cent (23\u2009012 of 148\u2009286) in idiopathic cases and 41\u00b76 per cent (4337 of 10 427 in patients with inflammatory bowel disease (IBD) (26\u00b77 per cent coded concurrently as ulcerative colitis; 47\u00b72 per cent coded as Crohn's disease). Of all patients who developed a fistula, 67\u00b75 per cent did so within the first year. Independent predictors of fistula formation were: IBD, in particular Crohn's disease (hazard ratio (HR) 3\u00b751; P\u2009<\u20090\u00b7001), ulcerative colitis (HR 1\u00b782; P\u2009<\u20090\u00b7001), female sex (HR 1\u00b718; P\u2009<\u20090\u00b7001), age at time of first abscess 41-60\u2009years (HR 1\u00b785 versus less than 20\u2009years; P\u2009<\u20090\u00b7001), and intersphincteric (HR 1\u00b753; P\u2009<\u20090\u00b7001) or ischiorectal (HR 1\u00b748; P\u2009<\u20090\u00b7001) abscess location compared with perianal. Some 2\u00b79 per cent of all patients presenting with a new abscess were subsequently diagnosed with Crohn's disease; the median time to diagnosis was 14\u2009months. CONCLUSION The burden of anorectal sepsis is high, with subsequent fistula formation nearly three times more common in Crohn's disease than idiopathic disease, and female sex is an independent predictor of fistula formation following abscess drainage. Most fistulas form within the first year of presentation with an abscess.", "author" : [ { "dropping-particle" : "", "family" : "Sahnan", "given" : "K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Askari", "given" : "A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Adegbola", "given" : "S. O.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tozer", "given" : "P. J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Phillips", "given" : "R. K. S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hart", "given" : "A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Faiz", "given" : "O. D.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "British Journal of Surgery", "id" : "ITEM-1", "issue" : "13", "issued" : { "date-parts" : [ [ "2017", "12" ] ] }, "page" : "1857-1865", "title" : "Natural history of anorectal sepsis", "type" : "article-journal", "volume" : "104" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "⁴", "plainTextFormattedCitation" : "4", "previouslyFormattedCitation" : "⁴" }, "properties" : { }, "schema" : "" }4 Previously reported rates from the literature vary from 26% to 87%.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0012-3706", "PMID" : "6697831", "abstract" : "To determine whether primary fistulotomy should be performed at the time of incision and drainage of anorectal abscesses, a retrospective study of 117 patients who underwent incision and drainage of anorectal abscesses was conducted to ascertain what percentage of patients would subsequently develop a fistula-in-ano or recurrent abscess. None of the patients treated for intersphincteric abscesses developed recurrences. Of the 83 patients with perianal or ischiorectal abscesses, nine (11 per cent) developed recurrent abscesses and 31 (37 per cent) developed persistent fistula-in-ano for a combined persistence or recurrence rate of 48 per cent. These data support the policy of secondary fistulotomy to avoid division of sphincter muscle in the 52 per cent of patients who would not need it. In addition, the vast majority of perianal and ischiorectal abscesses can be drained under local anesthesia and hence a general anesthetic and hospital admission are obviated.", "author" : [ { "dropping-particle" : "", "family" : "Vasilevsky", "given" : "C A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gordon", "given" : "P H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Diseases of the colon and rectum", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "1984", "2" ] ] }, "page" : "126-30", "title" : "The incidence of recurrent abscesses or fistula-in-ano following anorectal suppuration.", "type" : "article-journal", "volume" : "27" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "⁵", "plainTextFormattedCitation" : "5", "previouslyFormattedCitation" : "⁵" }, "properties" : { }, "schema" : "" }5,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0020-8868", "PMID" : "1270231", "author" : [ { "dropping-particle" : "V", "family" : "Raghavaiah", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "International surgery", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "1976", "4" ] ] }, "page" : "243-5", "title" : "Anal fistula in India.", "type" : "article-journal", "volume" : "61" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "⁶", "plainTextFormattedCitation" : "6", "previouslyFormattedCitation" : "⁶" }, "properties" : { }, "schema" : "" }6,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0095-4543", "PMID" : "9922295", "abstract" : "Anorectal abscesses and fistulas are seen commonly in the primary care practice. An abscess forms as the result of obstruction of an anal gland, with resulting retrograde infection. An anal fistula simply represents the chronic phase of a perianal abscess. The history generally is diagnostic, and special studies usually are not required. Treatment is surgical, with good results.", "author" : [ { "dropping-particle" : "", "family" : "Hyman", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Primary care", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "1999", "3" ] ] }, "page" : "69-80", "title" : "Anorectal abscess and fistula.", "type" : "article-journal", "volume" : "26" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "⁷", "plainTextFormattedCitation" : "7", "previouslyFormattedCitation" : "⁷" }, "properties" : { }, "schema" : "" }7,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0196-0644", "PMID" : "7741334", "abstract" : "STUDY OBJECTIVE: To review clinical features of perirectal abscesses and to determine appropriate management.\n\nDESIGN: Retrospective analysis of medical records.\n\nSETTING: Urban teaching hospital.\n\nPARTICIPANTS: Ninety-two patients with the discharge diagnosis of perirectal abscess over a 4-year period.\n\nRESULTS: Perirectal pain was the most common presenting symptom, being present in 98.9% of cases. External perianal and digital rectal examination identified an abscess in 94.6% of patients. A variety of aerobic and anaerobic bacteria from skin, bowel, and, rarely, vagina were identified as causative agents, with mixed infections common. The major complications of perirectal abscesses included formation of extensive abscesses and urine retention. Abscess resolution occurred in all patients after adequate drainage. Antibiotics appeared to be useful only as adjunct therapy.\n\nCONCLUSION: Effective management of perirectal abscess involves early, adequate drainage, with antibiotics in an adjunct role.", "author" : [ { "dropping-particle" : "", "family" : "Marcus", "given" : "R H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stine", "given" : "R J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cohen", "given" : "M A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Annals of emergency medicine", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "1995", "5" ] ] }, "page" : "597-603", "title" : "Perirectal abscess.", "type" : "article-journal", "volume" : "25" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "⁸", "plainTextFormattedCitation" : "8", "previouslyFormattedCitation" : "⁸" }, "properties" : { }, "schema" : "" }8,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0012-3706", "PMID" : "527452", "abstract" : "A prospective survey of patients with anorectal abscesses treated at Cook County Hospital over a 35-month period produced data on 474 patients. The peak incidence was in the third decade of life. Males were affected 1.76 times more frequently than females. Perianal abscess was the most common anatomic type (42 per cent), with ischiorectal abscess (20 per cent) being second. The supralevator space was involved in 7 per cent of the abscesses. Primary fistulotomy was performed when an anal fistula could be demonstrated (34 per cent). Our standardized method of treatment, utilizing radial incisions for drainage, produced satisfactory results with a complication rate of 3 per cent, an in-hospital reoperation rate of 0.6 per cent, and an average hospital stay of 5.7 days.", "author" : [ { "dropping-particle" : "", "family" : "Read", "given" : "D R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Abcarian", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Diseases of the colon and rectum", "id" : "ITEM-1", "issue" : "8", "issued" : { "date-parts" : [ [ "0", "1" ] ] }, "page" : "566-8", "title" : "A prospective survey of 474 patients with anorectal abscess.", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "⁹", "plainTextFormattedCitation" : "9", "previouslyFormattedCitation" : "⁹" }, "properties" : { }, "schema" : "" }9,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0009-4773", "PMID" : "6525691", "abstract" : "A study of 78 patients with recurrent anorectal abscess was carried out to elucidate the cause of recurrence. The inadequate treatment (incision and drainage) and the spontaneous rupture or resolution of the abscess with no further treatment were the most common reasons for recurrence. At surgery, 18 patients were found to have recurrent hidradenitis suppurativa. The authors recommend a careful regional exploration under anesthesia and an aggressive surgical approach to achieve satisfactory results and to ensure minimal, if any recurrence.", "author" : [ { "dropping-particle" : "", "family" : "Turra", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gherardi", "given" : "G M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mangiarotti", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Arrighi", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Chirurgia italiana", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "1984", "4" ] ] }, "page" : "266-71", "title" : "[Recurrent anorectal abscesses].", "type" : "article-journal", "volume" : "36" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹⁰", "plainTextFormattedCitation" : "10", "previouslyFormattedCitation" : "¹⁰" }, "properties" : { }, "schema" : "" }10,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0179-1958", "PMID" : "2033346", "abstract" : "In a five year period 227 patients with anal abscesses and/or fistulas of suspected cryptoglandular origin were observed and treated by one surgeon. In 201 patients the primary opening or the crypt of origin of the abscesses and/or fistulas were identified. These lesions were evaluated according to two classifications [1,2]. The aim was to verify whether primary abscesses and/or fistulas may spontaneously loop all the external sphincters and the puborectalis muscle as reported by Parks et al. [1] or whether the formation of tracks which loop all the striated sphincteric complex (Parks' supra- and extra-sphincteric fistulas) derives exclusively by the incorrect treatment of more superficial lesions, as suggested by Eisenhammer. Not one of the primary suppurative lesions (acute or chronic) looped the striated sphincteric complex (external sphincter-puborectalis muscle). Supra- and extrasphincteric tracks were observed only in the lesions which recurred after previous surgical treatment. The one-stage treatment of primary abscesses and fistulas (fistulotomy drainage or one-stage lay-open) with a few exceptions is a definitive (2% recurrence rate) and safe (4% prolonged impairment of continence rate) procedure.", "author" : [ { "dropping-particle" : "", "family" : "Fucini", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "International journal of colorectal disease", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "1991", "2" ] ] }, "page" : "12-6", "title" : "One stage treatment of anal abscesses and fistulas. A clinical appraisal on the basis of two different classifications.", "type" : "article-journal", "volume" : "6" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹¹", "plainTextFormattedCitation" : "11", "previouslyFormattedCitation" : "¹¹" }, "properties" : { }, "schema" : "" }11 This heterogeneity probably reflects differences in diagnosis, follow up and comorbidity, including the presence of Crohn’s disease. Clinical factors associated with persistent fistula formation after abscess drainage have also been examined. In the population based study described above, the single largest predictor of subsequent fistula formation was Crohn’s disease (CD) (HR 3?51, 3?38 to 3?63, p<0?001).ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/bjs.10614", "ISSN" : "00071323", "PMID" : "28857130", "abstract" : "BACKGROUND Progression from anorectal abscess to fistula is poorly described and it remains unclear which patients develop a fistula following an abscess. The aim was to assess the burden of anorectal abscess and to identify risk factors for subsequent fistula formation. METHODS The Hospital Episode Statistics database was used to identify all patients presenting with new anorectal abscesses. Cox regression analysis was undertaken to identify factors predictive of fistula formation. RESULTS A total of 165\u2009536 patients were identified in the database as having attended a hospital in England with an abscess for the first time between 1997 and 2012. Of these, 158\u2009713 (95\u00b79 per cent) had complete data for all variables and were included in this study, the remaining 6823 (4\u00b71 per cent) with incomplete data were excluded from the study. The overall incidence rate of abscess was 20\u00b72 per 100\u2009000. The rate of subsequent fistula formation following an abscess was 15\u00b75 per cent (23\u2009012 of 148\u2009286) in idiopathic cases and 41\u00b76 per cent (4337 of 10 427 in patients with inflammatory bowel disease (IBD) (26\u00b77 per cent coded concurrently as ulcerative colitis; 47\u00b72 per cent coded as Crohn's disease). Of all patients who developed a fistula, 67\u00b75 per cent did so within the first year. Independent predictors of fistula formation were: IBD, in particular Crohn's disease (hazard ratio (HR) 3\u00b751; P\u2009<\u20090\u00b7001), ulcerative colitis (HR 1\u00b782; P\u2009<\u20090\u00b7001), female sex (HR 1\u00b718; P\u2009<\u20090\u00b7001), age at time of first abscess 41-60\u2009years (HR 1\u00b785 versus less than 20\u2009years; P\u2009<\u20090\u00b7001), and intersphincteric (HR 1\u00b753; P\u2009<\u20090\u00b7001) or ischiorectal (HR 1\u00b748; P\u2009<\u20090\u00b7001) abscess location compared with perianal. Some 2\u00b79 per cent of all patients presenting with a new abscess were subsequently diagnosed with Crohn's disease; the median time to diagnosis was 14\u2009months. CONCLUSION The burden of anorectal sepsis is high, with subsequent fistula formation nearly three times more common in Crohn's disease than idiopathic disease, and female sex is an independent predictor of fistula formation following abscess drainage. Most fistulas form within the first year of presentation with an abscess.", "author" : [ { "dropping-particle" : "", "family" : "Sahnan", "given" : "K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Askari", "given" : "A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Adegbola", "given" : "S. O.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tozer", "given" : "P. J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Phillips", "given" : "R. K. S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hart", "given" : "A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Faiz", "given" : "O. D.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "British Journal of Surgery", "id" : "ITEM-1", "issue" : "13", "issued" : { "date-parts" : [ [ "2017", "12" ] ] }, "page" : "1857-1865", "title" : "Natural history of anorectal sepsis", "type" : "article-journal", "volume" : "104" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "⁴", "plainTextFormattedCitation" : "4", "previouslyFormattedCitation" : "⁴" }, "properties" : { }, "schema" : "" }4 It is likely that a combination of genetic, microbiological and immunological factors predisposes patients with CD to this elevated risk.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/ibd.21026", "ISSN" : "1536-4844", "PMID" : "19637358", "abstract" : "Perianal fistulation is a common complication of Crohn's disease (CD). Fistulating perianal CD appears to represent a distinct phenotype of CD, separate from luminal fistulating disease, with differing disease behavior and which often requires different therapeutic strategies. The etiology of Crohn's perianal fistulae appears to have genetic, microbiological, and immunological components. Relationships with IBD5, which codes for the organic/cation transporter and IRGM, important in the autophagy pathway, have been identified but further genetic associations remain elusive. The partially efficacious use of antibiotics and fecal diversion imply a microbiological component and, similarly, the partial efficacy of immunosuppressants and anti-tumor necrosis factor alpha (TNFalpha) treatments suggest not only that an immunological process is taking place, but also that microbiota alone cannot account for the pathogenesis. Recent work implicates failures in the tissue injury/repair process with myofibroblasts, matrix metalloproteinases, and an epithelial-to-mesenchymal transition being possible culprits. We examine these areas in a review of the current understanding of the etiology of Crohn's perianal fistulae.", "author" : [ { "dropping-particle" : "", "family" : "Tozer", "given" : "Philip J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Whelan", "given" : "Kevin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Phillips", "given" : "Robin K S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hart", "given" : "Ailsa L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Inflammatory bowel diseases", "id" : "ITEM-1", "issue" : "10", "issued" : { "date-parts" : [ [ "2009", "10" ] ] }, "page" : "1591-8", "title" : "Etiology of perianal Crohn's disease: role of genetic, microbiological, and immunological factors.", "type" : "article-journal", "volume" : "15" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹²", "plainTextFormattedCitation" : "12", "previouslyFormattedCitation" : "¹²" }, "properties" : { }, "schema" : "" }12 The other patient factor that is most associated with progression to fistula is the location of the abscess, specifically ischiorectal and intersphincteric abscess locations compared to perianal abscesses, although coding error may bias this finding.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/bjs.10614", "ISSN" : "00071323", "PMID" : "28857130", "abstract" : "BACKGROUND Progression from anorectal abscess to fistula is poorly described and it remains unclear which patients develop a fistula following an abscess. The aim was to assess the burden of anorectal abscess and to identify risk factors for subsequent fistula formation. METHODS The Hospital Episode Statistics database was used to identify all patients presenting with new anorectal abscesses. Cox regression analysis was undertaken to identify factors predictive of fistula formation. RESULTS A total of 165\u2009536 patients were identified in the database as having attended a hospital in England with an abscess for the first time between 1997 and 2012. Of these, 158\u2009713 (95\u00b79 per cent) had complete data for all variables and were included in this study, the remaining 6823 (4\u00b71 per cent) with incomplete data were excluded from the study. The overall incidence rate of abscess was 20\u00b72 per 100\u2009000. The rate of subsequent fistula formation following an abscess was 15\u00b75 per cent (23\u2009012 of 148\u2009286) in idiopathic cases and 41\u00b76 per cent (4337 of 10 427 in patients with inflammatory bowel disease (IBD) (26\u00b77 per cent coded concurrently as ulcerative colitis; 47\u00b72 per cent coded as Crohn's disease). Of all patients who developed a fistula, 67\u00b75 per cent did so within the first year. Independent predictors of fistula formation were: IBD, in particular Crohn's disease (hazard ratio (HR) 3\u00b751; P\u2009<\u20090\u00b7001), ulcerative colitis (HR 1\u00b782; P\u2009<\u20090\u00b7001), female sex (HR 1\u00b718; P\u2009<\u20090\u00b7001), age at time of first abscess 41-60\u2009years (HR 1\u00b785 versus less than 20\u2009years; P\u2009<\u20090\u00b7001), and intersphincteric (HR 1\u00b753; P\u2009<\u20090\u00b7001) or ischiorectal (HR 1\u00b748; P\u2009<\u20090\u00b7001) abscess location compared with perianal. Some 2\u00b79 per cent of all patients presenting with a new abscess were subsequently diagnosed with Crohn's disease; the median time to diagnosis was 14\u2009months. CONCLUSION The burden of anorectal sepsis is high, with subsequent fistula formation nearly three times more common in Crohn's disease than idiopathic disease, and female sex is an independent predictor of fistula formation following abscess drainage. Most fistulas form within the first year of presentation with an abscess.", "author" : [ { "dropping-particle" : "", "family" : "Sahnan", "given" : "K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Askari", "given" : "A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Adegbola", "given" : "S. O.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tozer", "given" : "P. J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Phillips", "given" : "R. K. S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hart", "given" : "A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Faiz", "given" : "O. D.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "British Journal of Surgery", "id" : "ITEM-1", "issue" : "13", "issued" : { "date-parts" : [ [ "2017", "12" ] ] }, "page" : "1857-1865", "title" : "Natural history of anorectal sepsis", "type" : "article-journal", "volume" : "104" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "⁴", "plainTextFormattedCitation" : "4", "previouslyFormattedCitation" : "⁴" }, "properties" : { }, "schema" : "" }4,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/DCR.0b013e31821cc1f9", "ISSN" : "1530-0358", "PMID" : "21730779", "abstract" : "BACKGROUND: The risk of fistula formation is a major concern after incision and drainage of an anorectal abscess.\n\nOBJECTIVE: Our objective was to the test the effects of antibiotic treatment on fistula formation after incision and drainage of anorectal abscesses.\n\nDESIGN: Randomized, placebo-controlled, double-blind study.\n\nSETTING: Multicenter trial at 3 teaching hospitals in Turkey.\n\nPATIENTS: Patients who underwent abscess drainage between September 2005 and January 2008 were evaluated for eligibility. Exclusion criteria included penicillin allergy, antimicrobial agent usage before enrolment, other infection, previous anorectal surgery, inflammatory bowel disease, suspicion of Fournier gangrene, secondary and recurrent anorectal abscesses, anal fistula at time of the surgery, immune compromised states, and pregnancy.\n\nINTERVENTION: Patients were randomly assigned to receive placebo or amoxicillin-clavulanic acid combination treatment for 10 days after abscess drainage.\n\nMAIN OUTCOME MEASURES: The primary end point was rate of anorectal fistula formation at 1-year follow-up.\n\nRESULTS: : Of 334 patients assessed for eligibility, 183 entered the study (placebo, 92; antibiotics, 91). Data were available for per-protocol analysis from 151 patients (placebo, 76; antibiotics, 75) with a mean age of 37.6 years; 118 patients (78.1%) were men. Overall, 45 patients (29.8%) developed anal fistulas during 1-year follow-up. Fistula formation occurred in 17 patients (22.4%) in the placebo group and in 28 patients (37.3%) in the antibiotic group (P = .044). Risk of fistula formation was increased in patients with ischiorectal abscess (odds ratio, 7.82) or intersphincteric abscess (odds ratio, 3.35) compared with perianal abscess.\n\nCONCLUSION: Antibiotic treatment following the drainage of an anorectal abscess has no protective effect regarding risk of fistula formation.", "author" : [ { "dropping-particle" : "", "family" : "S\u00f6zener", "given" : "Ulas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gedik", "given" : "Ercan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kessaf Aslar", "given" : "Ahmet", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ergun", "given" : "Hakan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Halil Elhan", "given" : "Atilla", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Memiko\u011flu", "given" : "Osman", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bulent Erkek", "given" : "Ayhan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ayhan Kuzu", "given" : "Mehmet", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Diseases of the colon and rectum", "id" : "ITEM-1", "issue" : "8", "issued" : { "date-parts" : [ [ "2011", "8" ] ] }, "page" : "923-9", "title" : "Does adjuvant antibiotic treatment after drainage of anorectal abscess prevent development of anal fistulas? A randomized, placebo-controlled, double-blind, multicenter study.", "type" : "article-journal", "volume" : "54" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹³", "plainTextFormattedCitation" : "13", "previouslyFormattedCitation" : "¹³" }, "properties" : { }, "schema" : "" }13 Determining the anatomical location of an anorectal abscess is dependent on the operating surgeon and it should be noted that incision and drainage operations are rarely performed by experienced proctologists. An observational study from the UK revealed that only 7.8% (10/128) of incision and drainage operations were performed by consultant surgeons, whereas 85.2% were performed by junior surgical trainees.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/bjs.10154", "ISSN" : "1365-2168", "PMID" : "27061287", "abstract" : "INTRODUCTION Management of perianal abscesses has remained largely unchanged for over 50\u2009years. The evidence for postoperative wound packing is limited and may expose patients to painful procedures with no clinical benefit and at considerable increased cost. METHODS Patients were recruited in 15 UK centres between December 2013 and October 2014. Outcome measures included number of dressing (pack) changes, healing, recurrence, return to work/normal function, postoperative fistula in\u2009ano and health utility scores (EQ-5D\u2122). Pain was measured before, during and after dressing change on a visual analogue scale. RESULTS Some 141 patients were recruited (median age 39 (range 18-86) years). The mean number of dressing changes in the first 3\u2009weeks was 13 (range 0-21), equating to an annual cost to the National Health Service of \u20ac6\u2009453\u2009360 in England alone per annum. Some 43\u00b78 per cent of wounds were healed by 8\u2009weeks after surgery and 86 per cent of patients had returned to normal function. Some 7\u00b76 per cent of abscesses had recurred and 26\u00b77 per cent of patients developed a fistula in\u2009ano by 6\u2009months following surgery. Patients reported a twofold to threefold increase in pain scores during and after dressing changes. CONCLUSION Recurrent abscess is rare and fistula occurs in one-quarter of the patients. Packing is painful and costly.", "author" : [ { "dropping-particle" : "", "family" : "Pearce", "given" : "L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Newton", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Smith", "given" : "S R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Barrow", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Smith", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hancock", "given" : "L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kirwan", "given" : "C C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hill", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "North West Research Collaborative", "given" : "", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The British journal of surgery", "id" : "ITEM-1", "issue" : "8", "issued" : { "date-parts" : [ [ "2016", "7" ] ] }, "page" : "1063-8", "title" : "Multicentre observational study of outcomes after drainage of acute perianal abscess.", "type" : "article-journal", "volume" : "103" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹⁴", "plainTextFormattedCitation" : "14", "previouslyFormattedCitation" : "¹⁴" }, "properties" : { }, "schema" : "" }14 Contrary to the findings of our population based study, being of male gender has recently been demonstrated as a risk factor for developing fistula (OR = 3.11; CI, 1.31–7.38 and p = 0.010) in a prospective randomised control trial (RCT) of 307 patients.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.surg.2017.07.001", "ISSN" : "1532-7361", "PMID" : "28822559", "abstract" : "BACKGROUND Much controversy exists regarding the role of antibiotics in the development of fistula in-ano after incision and drainage. We evaluated the role of postoperative antibiotics in the prevention of fistula in-ano after incision and drainage of perianal abscess. METHODS In a randomized single blind clinical trial study, 307 patients were randomly selected from those referring for incision and drainage of perianal abscess at Shahid Faghihi Hospital, Shiraz, Iran, during September 2013 to September 2014. Patients were allocated randomly either to receive 7\u00a0days of oral metronidazole and ciprofloxacin in addition to their standard care or to only receive standard care without any antibiotics after they were discharged from the hospital. Patients were followed for 3\u00a0months and final results were evaluated. The study was registered at the clinical trial registry (irct.ir; Irct201311049936n7). RESULTS Seven patients were lost to follow-up. Those who used prophylactic antibiotics (n\u00a0=\u00a0155) had significantly lower rates of fistula formation compared with those who did not use any medication (n\u00a0=\u00a0144; P\u00a0<\u00a0.001). Men had higher rates of fistula formation (P\u00a0=\u00a0.002). Patients who used more cigarettes had higher rates of fistula development (P\u00a0=\u00a0.001). In the univariate analysis, only postoperative\u00a0antibiotic use showed a protective role against fistula formation (odds ratio\u00a0=\u00a00.426; confidence interval, 0.206-0.881). In the regression analysis postoperative antibiotic use remained protective against fistula development (odds ratio\u00a0=\u00a00.371; confidence interval, 0.196-0.703), furthermore male sex presented as a risk factor for developing fistula in-ano (odds ratio\u00a0=\u00a03.11; confidence interval, 1.31-7.38). CONCLUSION Postoperative prophylactic antibiotic therapy including ciprofloxacin and metronidazole play an important role in preventing fistula in-ano formation. Considering the complications of fistula in-ano formation and the minor side effects of antibiotic therapy, based on our results, a 7-10 course of postoperative antibiotics is advised after incision and drainage of perianal abscess.", "author" : [ { "dropping-particle" : "", "family" : "Ghahramani", "given" : "Leila", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Minaie", "given" : "Mohammad Reza", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Arasteh", "given" : "Peyman", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hosseini", "given" : "Seyed Vahid", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Izadpanah", "given" : "Ahmad", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bananzadeh", "given" : "Ali Mohammad", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ahmadbeigi", "given" : "Mahboobe", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hooshanginejad", "given" : "Zahra", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Surgery", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2017", "11" ] ] }, "page" : "1017-1025", "title" : "Antibiotic therapy for prevention of fistula in-ano after incision and drainage of simple perianal abscess: A randomized single blind clinical trial.", "type" : "article-journal", "volume" : "162" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹⁵", "plainTextFormattedCitation" : "15", "previouslyFormattedCitation" : "¹⁵" }, "properties" : { }, "schema" : "" }15 An improved understanding of the overall rate of further perianal sepsis or persistent fistula formation after abscess drainage, and the risk factors that are associated with fistula, are important to enable stratification of patients at the time of abscess drainage, to determine both the operative plan and surgical follow-up.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1136/bmj.j475", "ISSN" : "0959-8138", "PMID" : "28223268", "abstract" : "#### What you need to know\n\nThe annual incidence of perianal abscess is estimated between 14\u2009000 and 20\u2009000 people in the UK, resulting in about 12\u2009500 operations in the NHS each year.1 A recent Swedish cohort study estimated the incidence at 16.1 per 100\u2009000.2 The true incidence may be higher, since many patients are treated with antibiotics in the community and some abscesses spontaneously regress or discharge.23 Patients usually present with an erythematous swelling near the anus and may be embarrassed or reluctant to seek treatment. They may present to a non-specialist in the first instance. This article provides information on the causes and different types of perianal abscess and an update on how they are best managed.\n\nAn abscess is a localised collection of infected fluid. Although there are strict anatomical definitions for the different anorectal abscesses, initial management is the same in most cases and the term \u201cperianal abscess\u201d is generally used as a result (fig 1\u21d3).\n\n\n\nFig 1 \u00a0Possible sites of anorectal (\u201cperianal\u201d) abscesses\n\n\n\nAbout 90% of idiopathic perianal abscesses occur because of infection of the cryptoglobular glands.45 Most occur posteriorly and in the intersphincteric space, where the anal glands are located.6 Abscesses are classified as superficial or deep in relation to the anal sphincter. If the infection bursts through the external sphincter, it will form an ischiorectal abscess. If it spreads laterally on both sides it can form a collection of sepsis, which \u2026", "author" : [ { "dropping-particle" : "", "family" : "Sahnan", "given" : "Kapil", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Adegbola", "given" : "Samuel O", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tozer", "given" : "Phillip J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Watfah", "given" : "Josef", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Phillips", "given" : "Robin KS", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Bmj", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2017" ] ] }, "page" : "j475", "title" : "Perianal abscess", "type" : "article-journal", "volume" : "475" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹⁶", "plainTextFormattedCitation" : "16", "previouslyFormattedCitation" : "¹⁶" }, "properties" : { }, "schema" : "" }16The aims of this paper are to interrogate the database of a busy district general hospital, to identify the patients with anorectal abscess, and determine the risk factors that are associated with subsequent fistula formation. In particular, we aimed to confirm the findings of the population study, which identified an increased risk of persistent fistula after abscess drainage for women, patients with Crohn’s disease and based on abscess location.MethodsICD-10 (International Classification of Disease, 10th revision) and OPCS (Classification of Interventions and Procedures, version 4) codes (Table 1) were used to identify all patients with primary anorectal abscess, those with progression to anal fistula and to note the presence of Crohn’s disease (CD), treated at Northwick Park General Hospital, a busy urban district general hospital with a diverse population, between March 2004 and November 2015. The data for adult patients (>16 years) were obtained from the coding department at the hospital. The data were interpreted and analysed by the Fistula Research Unit at St Mark’s Hospital, the adjacent tertiary referral centre. The abscess diagnosis was present prior to the fistula diagnosis, but the diagnosis of Crohn’s disease, where present, occurred at any point in the patient pathway. Pre-existing comorbidity was calculated using the Charlson Comorbidity Index. Demographic and disease data were analysed and compared between the CD and non-CD populations, and between those who did and did not develop a persistent fistula. Multivariable analysis sought to identify factors predictive of fistula formation.Statistical AnalysisFor comparison of groups, Chi Squared analyses were undertaken. Binary logistic regression analyses were carried out to determine factors associated with progression to fistula from baseline anorectal abscess. All variables were tested for association with the outcome separately. A p<0.010 was considered significant and the variable was included in a multivariable model. During multivariable analyses, variables with a p<0.05 were considered statistically significant and independently associated with the outcome. All analyses were carried out using Statistical Package for the Social Sciences (SPSS) version 21. ResultsOver this 11-year period, the median follow up was 45 months (Interquartile Range [IQR] 11-94) and a total of 1,970 patients had 2,797 episodes of anorectal abscess. Of the total population, 70.0% (n=1,379) were male and 7.3% (n=144) had a diagnosis of CD (Table 2). Across the population, the most commonly coded abscess type was perianal (85.6%), followed by ischiorectal (10.4%), intersphincteric, peri-rectal and anorectal. The rate of persistent fistula following abscess drainage was 16.2% (n=319) amongst the entire study population. However, patients with CD were more likely to present with fistulae after their initial anorectal abscess drainage compared with the non-CD population (32.6% vs. 14.9%, p<0.001). The median time to fistula formation was 7 months (IQR 3-7) overall, and was similar in the Crohn’s (8 months, IQR 3-14) and non-Crohn’s (6 months IQR 3-11) groups (p=0.064). When comparing the Crohn’s and non-Crohn’s patient who presented with an initial abscess (Table 3), the abscess location was similar. However, there were a higher proportion of women in the CD group than the non-CD group (45.1% vs. 28.8%, p<0.001). The median age at first abscess formation was lower in those with CD than those without (33yrs old, IQR 24-39 vs. 38 years old, IQR 28-50, p<0.005). Rates of diabetes and comorbidity were also lower in the CD group than the non-CD population. Amongst the patients who developed a fistula (n=319), a higher proportion of patients were female (55.3% vs. 34.6%, p=0.007) and young (<30 years old 51.1% vs. 24.3%, p<0.001) in the CD group than the non-CD population (Table 4). There were no differences in comorbidity or diabetes status between the CD and non-CD groups in the patients that formed a fistula. Regression analysis was undertaken to determine factors associated with progression from anorectal abscess to persistent fistula (Table 5). At univariable analyses; gender, existing comorbidities, a diagnosis of CD and diabetes were associated with progression from abscess to fistula. At multivariable analysis, men were less likely to develop a fistula than women (OR 0.7, 95% CI: 0.5-0.9, p=0.005), as were those with a diagnosis of diabetes mellitus (OR 0.5, 95% CI 0.3-0.9, p=0.027). Patients with CD were more than twice as likely to develop a fistula following abscess drainage than the non-CD population (OR 2.5, 95% CI: 1.7-3.7, p<0.001).Discussion We studied consecutive patients presenting with anorectal abscess to a district general hospital over an 11-year period. Men were more likely to present with an abscess overall and regardless of the presence of Crohn’s disease, but women were more likely to develop a persistent fistula following anorectal abscess drainage. One in seven patients developed a fistula following anorectal abscess drainage overall, rising to just under a third of patients with CD. Crohn’s disease increased the risk of persistent fistula after anorectal abscess drainage more than twofold. Patients with diabetes developed persistent fistula after abscess drainage less commonly than those without diabetes. Location of the anorectal abscess, comorbidity and patient age were not associated with an altered risk of fistula.The strength of this study is that the rate of, and risk factors associated with, fistula formation are in line with our previous administrative dataset study in England, corroborating the findings from the Hospital Episode Statistics (HES) database for perianal sepsis. In addition, it confirms our previous finding that female gender is a risk factor for developing a fistula, contrary to the findings of other studies, and surgical dogma. The accuracy of clinical data is continually improving and a systematic review demonstrated the overall median accuracy (routinely collected data sets compared with case notes) was 83.2% (IQR: 67.3-92.1%).ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1093/pubmed/fdr054", "ISSN" : "1741-3842", "PMID" : "21795302", "abstract" : "INTRODUCTION Routinely collected data sets are increasingly used for research, financial reimbursement and health service planning. High quality data are necessary for reliable analysis. This study aims to assess the published accuracy of routinely collected data sets in Great Britain. METHODS Systematic searches of the EMBASE, PUBMED, OVID and Cochrane databases were performed from 1989 to present using defined search terms. Included studies were those that compared routinely collected data sets with case or operative note review and those that compared routinely collected data with clinical registries. RESULTS Thirty-two studies were included. Twenty-five studies compared routinely collected data with case or operation notes. Seven studies compared routinely collected data with clinical registries. The overall median accuracy (routinely collected data sets versus case notes) was 83.2% (IQR: 67.3-92.1%). The median diagnostic accuracy was 80.3% (IQR: 63.3-94.1%) with a median procedure accuracy of 84.2% (IQR: 68.7-88.7%). There was considerable variation in accuracy rates between studies (50.5-97.8%). Since the 2002 introduction of Payment by Results, accuracy has improved in some respects, for example primary diagnoses accuracy has improved from 73.8% (IQR: 59.3-92.1%) to 96.0% (IQR: 89.3-96.3), P= 0.020. CONCLUSION Accuracy rates are improving. Current levels of reported accuracy suggest that routinely collected data are sufficiently robust to support their use for research and managerial decision-making.", "author" : [ { "dropping-particle" : "", "family" : "Burns", "given" : "E. M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rigby", "given" : "E.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mamidanna", "given" : "R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bottle", "given" : "A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Aylin", "given" : "P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ziprin", "given" : "P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Faiz", "given" : "O. D.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Public Health", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2012", "3", "1" ] ] }, "page" : "138-148", "title" : "Systematic review of discharge coding accuracy", "type" : "article-journal", "volume" : "34" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹⁷", "plainTextFormattedCitation" : "17", "previouslyFormattedCitation" : "¹⁷" }, "properties" : { }, "schema" : "" }17 However the use of coding data and the retrospective nature of this paper are both limitations. The coding of abscess location is particularly suspect. It is our view that ‘perianal abscess’ is used as a catch-all term by junior surgeons who are unfamiliar with the more nuanced classification of anorectal abscess used by experienced proctologists, or unable to employ it in the acute setting. This limits the present study’s ability to identify any association between abscess location and persistent fistula, an association one might expect to see based on the cryptoglandular hypothesis. However, in general, the volume of cases, the long data collection period and the similarity to the HES database outcomes, make the findings credible and generalizable. Abscess and fistula can co-exist. Indeed, some surgeons consider an abscess to be an ‘acute fistula’, and a fistula to be a ‘chronic abscess.’ This relates to the role of intersphincteric sepsis and a distinction between pathogenesis and persistence.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/s10151-017-1645-5", "ISSN" : "1123-6337", "PMID" : "28620877", "abstract" : "Anal fistulas continue to be a problem for patients and surgeons alike despite scientific advances. While patient and anatomical characteristics are important to surgeons who are evaluating patients with anal fistulas, their development and persistence likely involves a multifaceted interaction of histological, microbiological, and molecular factors. Histological studies have shown that anal fistulas are variably epithelialized and are surrounded by dense collagen tissue with pockets of inflammatory cells. Yet, it remains unknown if or how histological differences impact fistula healing. The presence of a perianal abscess that contains gut flora commonly leads to the development of anal fistula. This implies a microbiological component, but bacteria are infrequently found in chronic fistulas. Recent work has shown an increased expression of proinflammatory cytokines and epithelial to mesenchymal cell transition in both cryptoglandular and Crohn's perianal fistulas. This suggests that molecular mechanisms may also play a role in both fistula development and persistence. The aim of this study was to examine the histological, microbiological, molecular, and host factors that contribute to the development and persistence of anal fistulas.", "author" : [ { "dropping-particle" : "", "family" : "Sugrue", "given" : "Jeremy", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nordenstam", "given" : "Johan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Abcarian", "given" : "Herand", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bartholomew", "given" : "Amelia", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schwartz", "given" : "Joel L.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mellgren", "given" : "Anders", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tozer", "given" : "Philip J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Techniques in Coloproctology", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2017", "6", "15" ] ] }, "page" : "425-432", "title" : "Pathogenesis and persistence of cryptoglandular anal fistula: a systematic review", "type" : "article-journal", "volume" : "21" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹⁸", "plainTextFormattedCitation" : "18", "previouslyFormattedCitation" : "¹⁸" }, "properties" : { }, "schema" : "" }18 Further, acute abscesses often contain internal openings,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/s00384-002-0429-0", "ISSN" : "0179-1958", "PMID" : "12548410", "abstract" : "BACKGROUND AND AIMS: Anal abscess is a frequent acute proctological disorder and whether the underlying fistula should be treated at the same time when the abscess is drained remains controversial. We examined indications for drainage alone versus drainage plus fistulotomy in terms of recurrence and continence.\n\nPATIENTS AND METHODS: We carried out a randomized prospective study of 200 consecutive patients with anal abscess. One group received drainage alone, while in the other group drainage plus fistulotomy was performed when a subcutaneous-mucosa, low transsphincteral, or intersphincteral fistula was found. Delayed progressive fistulotomy with suture threads was performed in cases of high transsphincteric or suprasphincteric fistula.\n\nRESULTS: The internal opening of the fistula track was found in 83% of the patients. The recurrence rate was related to the surgical technique employed: 29% in the group with drainage alone and 5% in the group for which treatment of the fistula track was attempted. The incontinence rate was also related to the surgical option. In those receiving drainage and treatment of the fistula track incontinence was restricted mostly to patients with delayed fistulotomy (36.7%), compared to 2.8% of patients when simple fistulotomy was performed. There was no incontinence in the drainage alone group.\n\nCONCLUSION: Drainage of anal abscess with fistulotomy can be safely performed in cases of subcutaneous, intersphincteral, or low transsphincteral fistulae with a minimal recurrence rate. However, drainage alone and posterior treatment of the fistula track is recommended for high transsphincteral or suprasphincteral fistulae.", "author" : [ { "dropping-particle" : "", "family" : "Oliver", "given" : "I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lacueva", "given" : "F J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "P\u00e9rez Vicente", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Arroyo", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ferrer", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cansado", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Candela", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Calpena", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "International journal of colorectal disease", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2003", "3" ] ] }, "page" : "107-10", "title" : "Randomized clinical trial comparing simple drainage of anorectal abscess with and without fistula track treatment.", "type" : "article-journal", "volume" : "18" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹⁹", "plainTextFormattedCitation" : "19", "previouslyFormattedCitation" : "¹⁹" }, "properties" : { }, "schema" : "" }19 but not all abscesses with an internal opening end up developing a fistula.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0012-3706", "PMID" : "8969668", "abstract" : "PURPOSE Incision and drainage (I & D) with concurrent or delayed fistulotomy is the usual treatment for abscess-fistula with a demonstrated internal opening. We compared incision and drainage alone vs. with concurrent fistulotomy for perianal abscesses with a demonstrated internal opening. METHODS Consecutive patients with acute perianal abscesses and a demonstrated internal opening were prospectively randomized into either the I & D group or drainage with concurrent fistulotomy group. They were followed up at one month, three months, and one year. RESULTS The I & D group had 21 patients, and the fistulotomy group had 24 patients. Thirteen patients had low intersphincteric abscess-fistula, and seven had low transsphincteric fistulas in the I & D group. The fistulotomy group had 9 intersphincteric abscess-fistula compared with 14 low transsphincteric ones. Median duration of surgery, hospital stay, and continence at final follow-up were the same in the two groups. Three had recurrent abscess-fistula in the I & D group compared with none in the fistulotomy group (P = 0.09). CONCLUSION I & D alone for acute anal abscess-fistula with demonstrated internal opening showed a tendency to recurrence that did not reach a statistically significant difference compared with concurrent fistulotomy. I & D, therefore, puts only a few patients at risk for recurrence.", "author" : [ { "dropping-particle" : "", "family" : "Tang", "given" : "C L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chew", "given" : "S P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seow-Choen", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Diseases of the colon and rectum", "id" : "ITEM-1", "issue" : "12", "issued" : { "date-parts" : [ [ "1996", "12" ] ] }, "page" : "1415-7", "title" : "Prospective randomized trial of drainage alone vs. drainage and fistulotomy for acute perianal abscesses with proven internal opening.", "type" : "article-journal", "volume" : "39" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "²⁰", "plainTextFormattedCitation" : "20", "previouslyFormattedCitation" : "²⁰" }, "properties" : { }, "schema" : "" }20,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0012-3706", "PMID" : "9407981", "abstract" : "PURPOSE Primary fistulotomy may be advantageous for perianal abscesses because unlike ischiorectal abscesses, fistulas are more commonly found and can be laid open with full preservation of the external anal sphincters. Therefore, a randomized, controlled trial was conducted to compare primary fistulotomy with incision and drainage alone, specifically for perianal abscesses. METHODS Fifty-two consecutive patients (43 males; mean age, 40 (standard error of mean, 2) years) with perianal abscesses were randomized to treatment by either incision and drainage (controls; N = 28) or fistulotomy (N = 24). Patients were followed up clinically for a mean of 15.5 (standard error of the mean, 0.7) months. Anorectal manometry was also performed before, six weeks, and three months after surgery. RESULTS Persistent fistulas developing after surgery were significantly more common after incision and drainage (N = 7; 25 percent) than after fistulotomy (N = 0; P = 0.009). One patient in each group was also found to have a residual abscess, which required repeat drainage. All patients remained fully continent. The anal pressures after incision and drainage and fistulotomy were not significantly different. Operative time, hospital stay, and time for the wound to heal completely were the same in both groups. CONCLUSIONS Primary fistulotomy at the time of drainage for perianal abscesses results in fewer persistent fistulas and no added risk of fecal incontinence.", "author" : [ { "dropping-particle" : "", "family" : "Ho", "given" : "Y H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tan", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chui", "given" : "C H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Leong", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Eu", "given" : "K W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seow-Choen", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Diseases of the colon and rectum", "id" : "ITEM-1", "issue" : "12", "issued" : { "date-parts" : [ [ "1997", "12" ] ] }, "page" : "1435-8", "title" : "Randomized controlled trial of primary fistulotomy with drainage alone for perianal abscesses.", "type" : "article-journal", "volume" : "40" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "²¹", "plainTextFormattedCitation" : "21", "previouslyFormattedCitation" : "²¹" }, "properties" : { }, "schema" : "" }21 Our data suggest that men are at a greater risk of abscess formation, but not of persistent fistula. Hypotheses for this include that men either develop abscesses that are of an aetiology less likely to progress to fistula (superficial, skin based sepsis rather than cryptoglandular sepsis, for example), or they are protected from persistence by an absence of factors that drive this, compared to women. That diabetes is associated with a lower risk of persistent fistula following abscess drainage, supports the former hypothesis; if diabetes-related persistence factors were the key, one might expect the diabetic patient to have an increased or at least equivalent risk of fistula, whereas diabetes is likely to predispose to superficial perianal infections, as it does elsewhere. A Cochrane review of six RCTs concluded that treating the fistula in the acute setting reduced the risk of persistent abscess and the need for repeat surgery.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/14651858.CD006827.pub2", "ISSN" : "1469-493X", "PMID" : "20614450", "abstract" : "BACKGROUND: The perianal abscess is a common surgical problem. A third of perianal abscesses may manifest a fistula-in-ano which increases the risk of abscess recurrence requiring repeat surgical drainage. Treating the fistula at the same time as incision and drainage of the abscess may reduce the likelihood of recurrent abscess and the need for repeat surgery. However, this could affect sphincter function in some patients who may not have later developed a fistula-in-ano.\n\nOBJECTIVES: We aimed to review the available randomised controlled trial evidence comparing incision and drainage of perianal abscess with or without fistula treatment.\n\nSEARCH STRATEGY: Randomised trials were identified from MEDLINE, EMBASE, the Cochrane Library, and reference lists of published papers and reviews.\n\nSELECTION CRITERIA: Trials comparing outcome after fistula surgery with drainage of perianal abscess compared with drainage alone were included in the review.\n\nDATA COLLECTION AND ANALYSIS: The primary outcomes were recurrent or persistent abscess/fistula which may require repeat surgery and short-term and long-term incontinence. Secondary outcomes were duration of hospitalisation, duration of wound healing, postoperative pain, quality of life scores. For dichotomous variables, relative risks and their confidence intervals were calculated.\n\nMAIN RESULTS: We identified six trials, involving 479 subjects, comparing incision and drainage of perianal abscess alone versus incision and drainage with fistula treatment. Metaanalysis showed a significant reduction in recurrence, persistent abscess/fistula or repeat surgery in favour of fistula surgery at the time of abscess incision and drainage (RR=0.13, 95% Confidence Interval of RR = 0.07-0.24). Transient manometric reduction in anal sphincter pressures, without clinical incontinence, may occur after treatment of low fistulae with abscess drainage. Incontinence at one year following drainage with fistula surgery was not statistically significant (pooled RR 3.06, 95% Confidence Interval 0.7-13.45) with heterogeneity demonstrable between the trials (Chi(2) =5.39,df=3, p=0.14, I(2) =44.4%).\n\nAUTHORS' CONCLUSIONS: The published evidence shows fistula surgery with abscess drainage significantly reduces recurrence or persistence of abscess/fistula, or the need for repeat surgery. There was no statistically significant evidence of incontinence following fistula surgery with abscess drainage. This intervention may be recommended in ca\u2026", "author" : [ { "dropping-particle" : "", "family" : "Malik", "given" : "Ali Irqam", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nelson", "given" : "Richard L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tou", "given" : "Samson", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Cochrane database of systematic reviews", "id" : "ITEM-1", "issue" : "7", "issued" : { "date-parts" : [ [ "2010", "1" ] ] }, "page" : "CD006827", "title" : "Incision and drainage of perianal abscess with or without treatment of anal fistula.", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "²²", "plainTextFormattedCitation" : "22", "previouslyFormattedCitation" : "²²" }, "properties" : { }, "schema" : "" }22 However, the majority of non-Crohn’s abscesses with an internal opening will never develop into a fistula.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0012-3706", "PMID" : "9407981", "abstract" : "PURPOSE Primary fistulotomy may be advantageous for perianal abscesses because unlike ischiorectal abscesses, fistulas are more commonly found and can be laid open with full preservation of the external anal sphincters. Therefore, a randomized, controlled trial was conducted to compare primary fistulotomy with incision and drainage alone, specifically for perianal abscesses. METHODS Fifty-two consecutive patients (43 males; mean age, 40 (standard error of mean, 2) years) with perianal abscesses were randomized to treatment by either incision and drainage (controls; N = 28) or fistulotomy (N = 24). Patients were followed up clinically for a mean of 15.5 (standard error of the mean, 0.7) months. Anorectal manometry was also performed before, six weeks, and three months after surgery. RESULTS Persistent fistulas developing after surgery were significantly more common after incision and drainage (N = 7; 25 percent) than after fistulotomy (N = 0; P = 0.009). One patient in each group was also found to have a residual abscess, which required repeat drainage. All patients remained fully continent. The anal pressures after incision and drainage and fistulotomy were not significantly different. Operative time, hospital stay, and time for the wound to heal completely were the same in both groups. CONCLUSIONS Primary fistulotomy at the time of drainage for perianal abscesses results in fewer persistent fistulas and no added risk of fecal incontinence.", "author" : [ { "dropping-particle" : "", "family" : "Ho", "given" : "Y H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tan", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chui", "given" : "C H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Leong", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Eu", "given" : "K W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seow-Choen", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Diseases of the colon and rectum", "id" : "ITEM-1", "issue" : "12", "issued" : { "date-parts" : [ [ "1997", "12" ] ] }, "page" : "1435-8", "title" : "Randomized controlled trial of primary fistulotomy with drainage alone for perianal abscesses.", "type" : "article-journal", "volume" : "40" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "²¹", "plainTextFormattedCitation" : "21", "previouslyFormattedCitation" : "²¹" }, "properties" : { }, "schema" : "" }21,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0012-3706", "PMID" : "8969668", "abstract" : "PURPOSE Incision and drainage (I & D) with concurrent or delayed fistulotomy is the usual treatment for abscess-fistula with a demonstrated internal opening. We compared incision and drainage alone vs. with concurrent fistulotomy for perianal abscesses with a demonstrated internal opening. METHODS Consecutive patients with acute perianal abscesses and a demonstrated internal opening were prospectively randomized into either the I & D group or drainage with concurrent fistulotomy group. They were followed up at one month, three months, and one year. RESULTS The I & D group had 21 patients, and the fistulotomy group had 24 patients. Thirteen patients had low intersphincteric abscess-fistula, and seven had low transsphincteric fistulas in the I & D group. The fistulotomy group had 9 intersphincteric abscess-fistula compared with 14 low transsphincteric ones. Median duration of surgery, hospital stay, and continence at final follow-up were the same in the two groups. Three had recurrent abscess-fistula in the I & D group compared with none in the fistulotomy group (P = 0.09). CONCLUSION I & D alone for acute anal abscess-fistula with demonstrated internal opening showed a tendency to recurrence that did not reach a statistically significant difference compared with concurrent fistulotomy. I & D, therefore, puts only a few patients at risk for recurrence.", "author" : [ { "dropping-particle" : "", "family" : "Tang", "given" : "C L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chew", "given" : "S P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seow-Choen", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Diseases of the colon and rectum", "id" : "ITEM-1", "issue" : "12", "issued" : { "date-parts" : [ [ "1996", "12" ] ] }, "page" : "1415-7", "title" : "Prospective randomized trial of drainage alone vs. drainage and fistulotomy for acute perianal abscesses with proven internal opening.", "type" : "article-journal", "volume" : "39" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "²⁰", "plainTextFormattedCitation" : "20", "previouslyFormattedCitation" : "²⁰" }, "properties" : { }, "schema" : "" }20,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/s00384-002-0429-0", "ISSN" : "0179-1958", "PMID" : "12548410", "abstract" : "BACKGROUND AND AIMS: Anal abscess is a frequent acute proctological disorder and whether the underlying fistula should be treated at the same time when the abscess is drained remains controversial. We examined indications for drainage alone versus drainage plus fistulotomy in terms of recurrence and continence.\n\nPATIENTS AND METHODS: We carried out a randomized prospective study of 200 consecutive patients with anal abscess. One group received drainage alone, while in the other group drainage plus fistulotomy was performed when a subcutaneous-mucosa, low transsphincteral, or intersphincteral fistula was found. Delayed progressive fistulotomy with suture threads was performed in cases of high transsphincteric or suprasphincteric fistula.\n\nRESULTS: The internal opening of the fistula track was found in 83% of the patients. The recurrence rate was related to the surgical technique employed: 29% in the group with drainage alone and 5% in the group for which treatment of the fistula track was attempted. The incontinence rate was also related to the surgical option. In those receiving drainage and treatment of the fistula track incontinence was restricted mostly to patients with delayed fistulotomy (36.7%), compared to 2.8% of patients when simple fistulotomy was performed. There was no incontinence in the drainage alone group.\n\nCONCLUSION: Drainage of anal abscess with fistulotomy can be safely performed in cases of subcutaneous, intersphincteral, or low transsphincteral fistulae with a minimal recurrence rate. However, drainage alone and posterior treatment of the fistula track is recommended for high transsphincteral or suprasphincteral fistulae.", "author" : [ { "dropping-particle" : "", "family" : "Oliver", "given" : "I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lacueva", "given" : "F J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "P\u00e9rez Vicente", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Arroyo", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ferrer", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cansado", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Candela", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Calpena", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "International journal of colorectal disease", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2003", "3" ] ] }, "page" : "107-10", "title" : "Randomized clinical trial comparing simple drainage of anorectal abscess with and without fistula track treatment.", "type" : "article-journal", "volume" : "18" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹⁹", "plainTextFormattedCitation" : "19", "previouslyFormattedCitation" : "¹⁹" }, "properties" : { }, "schema" : "" }19 Also, there is a considerable risk of iatrogenic injury in the hands of inexperienced surgeons. Whilst there is likely to be global disparity, a recent observational study from the UK demonstrated that more than 85% of incision and drainage operations are performed by junior trainees, usually during daytime hours.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/bjs.10154", "ISSN" : "1365-2168", "PMID" : "27061287", "abstract" : "INTRODUCTION Management of perianal abscesses has remained largely unchanged for over 50\u2009years. The evidence for postoperative wound packing is limited and may expose patients to painful procedures with no clinical benefit and at considerable increased cost. METHODS Patients were recruited in 15 UK centres between December 2013 and October 2014. Outcome measures included number of dressing (pack) changes, healing, recurrence, return to work/normal function, postoperative fistula in\u2009ano and health utility scores (EQ-5D\u2122). Pain was measured before, during and after dressing change on a visual analogue scale. RESULTS Some 141 patients were recruited (median age 39 (range 18-86) years). The mean number of dressing changes in the first 3\u2009weeks was 13 (range 0-21), equating to an annual cost to the National Health Service of \u20ac6\u2009453\u2009360 in England alone per annum. Some 43\u00b78 per cent of wounds were healed by 8\u2009weeks after surgery and 86 per cent of patients had returned to normal function. Some 7\u00b76 per cent of abscesses had recurred and 26\u00b77 per cent of patients developed a fistula in\u2009ano by 6\u2009months following surgery. Patients reported a twofold to threefold increase in pain scores during and after dressing changes. CONCLUSION Recurrent abscess is rare and fistula occurs in one-quarter of the patients. Packing is painful and costly.", "author" : [ { "dropping-particle" : "", "family" : "Pearce", "given" : "L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Newton", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Smith", "given" : "S R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Barrow", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Smith", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hancock", "given" : "L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kirwan", "given" : "C C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hill", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "North West Research Collaborative", "given" : "", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The British journal of surgery", "id" : "ITEM-1", "issue" : "8", "issued" : { "date-parts" : [ [ "2016", "7" ] ] }, "page" : "1063-8", "title" : "Multicentre observational study of outcomes after drainage of acute perianal abscess.", "type" : "article-journal", "volume" : "103" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹⁴", "plainTextFormattedCitation" : "14", "previouslyFormattedCitation" : "¹⁴" }, "properties" : { }, "schema" : "" }14 It is not implausible to hypothesise that inexperienced trainees often make smaller more conservative incisions and as such do not adequately drain the pus, which may lead to the undrained collections that fistulate. Identification of ‘at risk’ patients could influence operative factors such as, the level of supervision for these patients, and the nature and urgency of their surgical follow up and investigations. We have considered some demographic factors that might influence fistula persistence following anorectal abscess drainage, prompted by our previous study at the national administrative dataset level. There are a number of factors that have not been evaluated: such as the role of smoking, use of antibiotics, use of immunodulators, obesity (BMI) and post-operative packing, which may have a role in subsequent fistula development. In addition, not all co-morbidities are encompassed within the Charlson Comorbidity Index and whilst imperfect this scoring system has been used widely in medical literature. Another limitation of this study is the difficulty in determining how to categorise the Crohn’s patients’. Patients were labelled as having Crohn’s if they were identified with a diagnosis of Crohn’s at any time point. It is therefore possible that certain patients (particularly those with short follow up) have been labelled as having a Crohn’s abscess/fistula even though at that point in time they had not developed Crohn’s yet. However, it is known that diagnosis in Crohn’s disease often occurs sometime after symptoms have begun and also that Crohn’s perianal fistula can predate the diagnosis of luminal Crohn’s. Furthermore, the aetiological processes underpinning fistula formation and persistence following development of an abscess remain poorly understood. In a way a fistula can be thought of as a “chronic abscess”, which has persisted after the majority of acute abscesses simply resolve. The factors leading to persistence, or in other words, the factors which determine why one patient’s abscess resolves when another’s becomes a fistula, are not fully understood, but are thought to be separate to the original pathology which sparked the acute abscess, generally accepted to be cryptoglandular infection, at least in non-Crohn’s patients.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/s10151-017-1645-5", "ISSN" : "1123-6337", "PMID" : "28620877", "abstract" : "Anal fistulas continue to be a problem for patients and surgeons alike despite scientific advances. While patient and anatomical characteristics are important to surgeons who are evaluating patients with anal fistulas, their development and persistence likely involves a multifaceted interaction of histological, microbiological, and molecular factors. Histological studies have shown that anal fistulas are variably epithelialized and are surrounded by dense collagen tissue with pockets of inflammatory cells. Yet, it remains unknown if or how histological differences impact fistula healing. The presence of a perianal abscess that contains gut flora commonly leads to the development of anal fistula. This implies a microbiological component, but bacteria are infrequently found in chronic fistulas. Recent work has shown an increased expression of proinflammatory cytokines and epithelial to mesenchymal cell transition in both cryptoglandular and Crohn's perianal fistulas. This suggests that molecular mechanisms may also play a role in both fistula development and persistence. The aim of this study was to examine the histological, microbiological, molecular, and host factors that contribute to the development and persistence of anal fistulas.", "author" : [ { "dropping-particle" : "", "family" : "Sugrue", "given" : "Jeremy", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nordenstam", "given" : "Johan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Abcarian", "given" : "Herand", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bartholomew", "given" : "Amelia", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schwartz", "given" : "Joel L.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mellgren", "given" : "Anders", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tozer", "given" : "Philip J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Techniques in Coloproctology", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2017", "6", "15" ] ] }, "page" : "425-432", "title" : "Pathogenesis and persistence of cryptoglandular anal fistula: a systematic review", "type" : "article-journal", "volume" : "21" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹⁸", "plainTextFormattedCitation" : "18", "previouslyFormattedCitation" : "¹⁸" }, "properties" : { }, "schema" : "" }18 Future studies into the microbiological, immunological, molecular and wound healing factors that predispose to fistula formation may yield biomarkers that would help predict which patients will develop a persistent fistula following abscess presentation.Figure LegendTable 1: ICD-10 and OPCS codes used to identify patients with abscess, fistula, IBD & diabetes mellitusTable 2: Population demographicsTable 3: Demographics for patients with abscessTable 4: Demographics for patients with fistulaTable 5: Factors associated with formation of anorectal fistula following a diagnosis of anorectal abscessReferencesADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY 1. Grace RH, Harper IA, Thompson RG. Anorectal sepsis: microbiology in relation to fistula-in-ano. Br J Surg. 1982;69:401-403.2. Xu RW, Tan K-K, Chong C-S. Bacteriological study in perianal abscess is not useful and not cost-effective. ANZ J Surg. 2016;86:782-784. 3. Sangwan YP, Rosen L, Riether RD, Stasik JJ, Sheets JA, Khubchandani IT. Is simple fistula-in-ano simple? Dis Colon Rectum. 1994;37:885-889. 4. Sahnan K, Askari A, Adegbola SO, et al. Natural history of anorectal sepsis. Br J Surg. 2017;104:1857-1865. 5. Vasilevsky CA, Gordon PH. The incidence of recurrent abscesses or fistula-in-ano following anorectal suppuration. Dis Colon Rectum. 1984;27:126-130. 6. Raghavaiah N V. Anal fistula in India. Int Surg. 1976;61:243-245. 7. Hyman N. Anorectal abscess and fistula. Prim Care. 1999;26:69-80. 8. Marcus RH, Stine RJ, Cohen MA. Perirectal abscess. Ann Emerg Med. 1995;25:597-603. 9. Read DR, Abcarian H. A prospective survey of 474 patients with anorectal abscess. Dis Colon Rectum. 22:566-568. 10. Turra G, Gherardi GM, Mangiarotti S, Arrighi E. Recurrent anorectal abscesses. Chir Ital. 1984;36:266-271. 11. Fucini C. One stage treatment of anal abscesses and fistulas. A clinical appraisal on the basis of two different classifications. Int J Colorectal Dis. 1991;6:12-16. 12. Tozer PJ, Whelan K, Phillips RKS, Hart AL. Etiology of perianal Crohn’s disease: role of genetic, microbiological, and immunological factors. Inflamm Bowel Dis. 2009;15:1591-1598. 13. S?zener U, Gedik E, Kessaf Aslar A, et al. Does adjuvant antibiotic treatment after drainage of anorectal abscess prevent development of anal fistulas? A randomized, placebo-controlled, double-blind, multicenter study. Dis Colon Rectum. 2011;54:923-929. 14. Pearce L, Newton K, Smith SR, et al. Multicentre observational study of outcomes after drainage of acute perianal abscess. Br J Surg. 2016;103:1063-1068. 15. Ghahramani L, Minaie MR, Arasteh P, et al. Antibiotic therapy for prevention of fistula in-ano after incision and drainage of simple perianal abscess: A randomized single blind clinical trial. Surgery. 2017;162:1017-1025. 16. Sahnan K, Adegbola SO, Tozer PJ, Watfah J, Phillips RK. Perianal abscess. Bmj. 2017;475:j475. 17. Burns EM, Rigby E, Mamidanna R, et al. Systematic review of discharge coding accuracy. J Public Health (Bangkok). 2012;34:138-148. 18. Sugrue J, Nordenstam J, Abcarian H, et al. Pathogenesis and persistence of cryptoglandular anal fistula: a systematic review. Tech Coloproctol. 2017;21:425-432. 19. Oliver I, Lacueva FJ, Pérez Vicente F, et al. Randomized clinical trial comparing simple drainage of anorectal abscess with and without fistula track treatment. Int J Colorectal Dis. 2003;18:107-110. 20. Tang CL, Chew SP, Seow-Choen F. Prospective randomized trial of drainage alone vs. drainage and fistulotomy for acute perianal abscesses with proven internal opening. Dis Colon Rectum. 1996;39:1415-1417. 21. Ho YH, Tan M, Chui CH, Leong A, Eu KW, Seow-Choen F. Randomized controlled trial of primary fistulotomy with drainage alone for perianal abscesses. Dis Colon Rectum. 1997;40:1435-1438. 22. Malik AI, Nelson RL, Tou S. Incision and drainage of perianal abscess with or without treatment of anal fistula. Cochrane database Syst Rev. 2010;CD006827. ................
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