anorectal suppuration 9.7.11!1!1

8/16/2019 Anorectal Suppuration 9.7.11!1!1

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AnoRectalAbscess and Fistula

Dino Mendez


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Anatomy

• Rectum (Retroperitoneal) – Sigmoid colon to

anorectal line

• Surgical Anal canal

– Anorectal line (orpuborectalis) to analverge

• Anatomical Anal canal

– Dentate line to anal verge

• Anal Margin

– Extends laterally from teanal verge all around fora distance of ! cm


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Anatomy & Muscles

• 'nternalspincter

•Externalspincter

• 'nterspincteric groove

• #uborectalis(evator ani)


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Anatomy + Muscles


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Anorectal Angle


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Anatomy & Anorectal Spaces

• #erianal

• 'scioanal"'sciorectal

• 'nterspincteric

•Supralevator•Deep postanal space

(Space of $ourtney)


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Anatomy & Anorectal Spaces#erianal and #erirectal Spaces


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Anorectal SuppurationEpidemiology

• Anorectal abscesses (0Acute pase1)

– 233333 cases per year

– Age range 43+53 462 ratio M6F

– 738 recurrence rate

• Anorectal 9stula (0$ronic pase1)

– 4!+:38 of abscesses lead to 9stula

– 23+438 recurrence rate


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Anorectal SuppurationEtiology

• *Cryptoglandular* (90%)

• Malignancy

• 'nfectious+ actinomycosislympogranuloma vernerum ;'s diverticulitis appendicitis #'D

• =rauma"Surgery


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$lassi9cation of AnorectalAbscesses


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$lassi9cation of AnorectalAbscesses

Supralevator abscess MUST r/u intraabdominal process


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Anorectal Abscess$linical #resentation

• ;x – Severe constant pain – Fevers"cill – Malaise

– Drainage (relieves pain) – $onstipation *rinaryretention

• Exam – 'nduration

?uctuanceerytema @armtpurulent drainage

– DRE


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Anorectal Abscess =reatment

• '/D+ cruciate or ellipticalincision

• Antibiotics $ulture


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Anorectal Abscess =reatment

• '/D+ cruciate or elliptical incision

• Antibiotics $ulture – 'ndications6

• 'mmunosuppression

• s dz

• #ropylactic 9stulotomy• Sitz Bats


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• Perianal- ER

• Ischiorectal- ER or OR

• Intersphincteric- OR

• Supralevator- OR (solve etiology!)

• Horse-shoe- OR

Anorectal Abscess'/D & ED vs CR


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'/D of te abscess• Drainage of an abscess (especially

isciorectal abscess) re-uires someplanning because te condition may@ell be associated @it te subse-uentdevelopment of a 9stula. 't is importantterefore to drain te abscess bycreating an external opening as close tote anal verge as is possible. 'f tis is

not considered te subse-uent9stulotomy may result in a larger @oundtat re-uires a long time to eal.


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Anorectal Fistula(Fistula+in+Ano)

• 0$ronic form1 of anorectalabscesses

• $onnection"tract bet@een

t@o epitelial+line structures – 'nternal opening+ Anal crypt of te

gland

– External opening+ #erianal"#erinealsin

• Cter6 rectovesicular rectovaginal rectouretral

9stula


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#ar>s $lassi9cation of AnorectalFistulas

• Type 1 –Intersphincteric,most common

• =ype 4 &

=ranspincteric• =ype 7 &

Supraspincteric

• =ype : +Extraspincteric


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#ar>s $lassi9cation of AnorectalFistulas


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Anorectal Fistula$linical #resentation

• ;x

– $ronic drainage from0nonealing abscess1

– #ain @it defecation

– #ruritus

• #ysical exam

– Draining pustule

– Erytema indurationexcoriated sin

– DRE+ 9rm cord (9stulatract)


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$aution & ecrotizingFasciitis


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Anorectal FistulaDiagnosis


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Anorectal FistulaManagement

• oals of =erapy

– Drain local infection

– Eradicate 9stulous tract

– Avoid recurrence @ile preserving nativespincter function


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Anorectal FistulaManagement

• Simple Fistula+ minimal or noinvolvement of external spincter orpuborectalis

– e.g. 'nterspincteric lo@+lying =ransspincteric

• $omplex Fistula – 'nvolvement of G 738 of external spincter

– Supraspincteric

– Extraspincteric or ig 9stulas (proximal to dentate line) – Fistulas @it multiple tracts

– Recurrent 9stulas

– Fistulas related to 'BD infection (=B ;'


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Anorectal FistulasManagement

• Simple Fistulas

– *#istulotomy*+ lay open 9stula tractmae incision over entire lengt of

9stula using probe as guide• Recurrence rate H 3+438

– Fibrin plug G Fibrin glue

• Recurrence rate H 73+5!8• Advantage+ preserve spincter function


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Anorectal FistulasManagement of Simple Fistulas

Fistulotomy


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Fibrin #lug


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Fibrin

lue



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• $omplex Fistula – *Cutting $eton ($taged #istulotomy)*+

tigtening of seton at regular intervals allo@s for slo@transection of muscle minimizing spincter

dysfunction• Recurrence H 3+2I8

• 'ncontinence rate H 3+738

– Mucosal advancement ?ap+ mobilize ?ap tatcovers te internal 9stulous opening

• 'ndication H recurrent 9stula

• Recurrence H 3+758

• 'ncontinence rate H 3+278

Anorectal FistulasManagement


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• $utting seton (staged 9stulotomy) – =read sil suture troug 9stula tract tie

togeter on outside

– 'ncise SJ' CK over 9stula tract – =igten seton at regular intervals slo@ly

cutting troug spincter

– radual cutting causes muscle scarring

leaving muscle ends near usual locationafter being transected tus minimizingdisruption of spincter and decreasingris of incontinence

Anorectal FistulasManagement of $omplex Fistulas


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$utting Seton (Staged Fistulotomy)


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Mucosal advancement ?ap



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Luestions

• :! y"o F @it DM4 (;gbA2c H 5.4)presents @it 4+day "o acute perirectalpain. Cn exam a tender ?uctuant mass

is present to te left of te anus. attreatment sould be administered attis time

a. Broad spectrum antibiotics

b. Abscess drainage and excision of 9stuloustract

c. 'ncision and drainage of abscess

d. $ontinued observation

e. =reatment of $ron>s disease


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Luestions

• :! y"o F @it DM4 (;gbA2c H 5.4)presents @it 4+day "o acute perirectalpain. Cn exam a tender ?uctuant mass

is present to te left of te anus. attreatment sould be administered attis time

a. Broad spectrum antibiotics

b. Abscess drainage and excision of 9stulous tract

c Incision and drainage o! a&scessd. $ontinued observation

e. =reatment of $ron>s disease


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Luestions

• Regarding 9stula in ano6

a. =e ma,ority are interspicteric

b. =ey usually follo@ a curvilinear course

to te midline if arising in anterior analcrypts

c. #ersistent drainage after 9stulotomy

indicates presence of $ron>s diseased. Seton placement sould be rarely

re-uired


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Luestions

• Regarding 9stula in ano6

a The ma'ority are intersphicteric

b. =ey usually follo@ a curvilinear course

to te midline if arising in anterior analcrypts

c. #ersistent drainage after 9stulotomy

indicates presence of $ron>s diseased. Seton placement sould be rarely

re-uired


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Luestions

• Anorectal abscesses are infectionstat typically6

a. Criginate @itin anal crypt glands

b. Resolve completely @itout se-ualaeafter '/D

c. Form orsesoe extensions

d. Cccur in pts @o areimmunocompromised

e. $an be treated early @it antibiotics


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Luestions

• Anorectal abscesses are infections tattypically6

a riginate within anal crypt

glandsb. Resolve completely @itout se-ualae after

'/D

c. Form orsesoe extensions

d. Cccur in pts @o are immunocompromised

e. $an be treated early @it antibiotics


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+ith regard to the anal sphinctericmechanism, which o! the !ollowingstatements isare true-

A. =e teniae of te colon ticen to form teinternal spincter

B. 'nternal spincter is made up of smoot muscle

and surrounds te distal t@o+tirds of te analcanal

$. External spincter is made up of striated muscle

D. #uborectalis is responsible for te anorectal angle

E. =e anorectal ring is composed of te palpabledeep portion of external spincter


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+ith regard to the anal sphinctericmechanism, which o! the !ollowing

statements isare true-

A. =e teniae of te colon ticen to form teinternal spincter

. Internal sphincter is made up o!smooth muscle and surrounds thedistal two/thirds o! the anal canal

C ternal sphincter is made up o!striated muscle

2 3u&orectalis is responsi&le !or the

anorectal angle


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Q: With regard to the anatomy of the anal canal,

which of the following statements is/are true?

A. The entate line lies aove the colu"ns o#

$orgagni

%. Anal glan ucts open into the anal crypts

&. Anal glans never e'ten eyon the internal

sphincter

. The colu"ns o# $orgagni overlie the internal

he"orrhoial ple'usE. The epitheliu" aove the entate line is innervate

y the autono"ic nervous syste"


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Q: With regard to the anatomy of the anal canal,

which of the following statements is/are true?

A. The entate line lies aove the colu"ns o#

$orgagni

B. Anal gland ducts open into the anal crypts

&. Anal glans never e'ten eyon the internal

sphincter

D. The columns of orgagni o!erlie the internal

hemorrhoidal ple"us#. The epithelium a$o!e the dentate line is

inner!ated $y the autonomic ner!ous system


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Q: hat is *oosall+s rule,


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A%&'#(TA) *+T-)A

Goodsall’s Rule

• E'ternal opening anterior to this

line an ithin c"s #ro" anal

verge ill lea to a straight raial

tract

• E'ternal opening posterior to the

line ill lea to a curve tract an

an internal opening in the posterior

"iline

• /ong anterior #istula (0 c"s #ro"

anal verge) has a curve tract an an

internal opening in the posterior

"iline


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Q: With regard to the management of patients withfistula in ano, which of the following statementsis/are true?

A. All internal openings o# #istulas are locate posteriorlyaccoring to *oosall+s rule

%. The "ost co""on type o# #istula is intersphincteric

&. E'cision o# the entire #istulous tract is necessary #or cure

. High #istulas are "anage y seton suture

E. A horseshoe #istula can e treate y posterior "iline internalsphincteroto"y co"ine ith opening the eep postanal space


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Q: With regard to the management of patients withfistula in ano, which of the following statementsis/are true?

A. All internal openings o# #istulas are locate posteriorlyaccoring to *oosall+s rule

B. The most common type of fistula is intersphincteric

&. E'cision o# the entire #istulous tract is necessary #or cure

D. igh fistulas are managed $y seton suture

#. A horseshoe fistula can $e treated $y posterior

midline internal sphincterotomy com$ined withopening the deep postanal space

anorectal suppuration 9.7.11!1!1

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