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Perianal abscess and fistula-in-ano in infants
Perianal
Abscess and Fistula-in-An0
in Infants
By C. Festen and H. van Hat-ten Nijmegen,
Purpose:The aim of this study was to obtain insight shortand long-term results of treatment of perianal and fistula-in-ano in infants.
The
into the abscess
Methods: This is a retrospective study of the records of patients treated over a 21-year period from January 1974 until December 1994 in a Pediatric Surgical Center. A longterm (1 to 24 year, mean 7.74 year) follow-up by questionaire (response 81%) is also included. Results: Drainage of a perianal abscess is followed in 35% of cases by a fistula. Fistulotomy or fistulectomy is followed in 13% of cases by a recurrence. There were two long-term recurrences that both healed spontaneously. The persisting scar sometimes gives problems with anal cleaning. All chil-
A
PERIANAL ABSCESS and/or fistula-in-ano in infants are more trivial diseases that are seen regularly in a pediatric surgical center. Exact numbers about the frequency are not available. In some large series of patients with perianal fistula reported in the literature 0.5% to 4.3% are children.‘m3 The cases presented here are highly selected as they are in most reports. There is little written in the literature about this problem, and the largest series, of 50 cases, was reported by Duhamel in 1975.4 In childhood, the disease presents in 57% to 86% of casesbefore 1 year of age.4-9There is an overwhelming male preponderance.3%7-11Although the disease starts nearly always as a perianal abscess (18% to 92%),3,5*7J2J3there are many arguments for a congenital origin. Most abscesses and fistulae are located laterally,4 equally divided between left and right.5J3 The usual treatment of a perianal abscess is incision and drainage, but it will be followed in 28% to 85% of cases by a fistula.4J0J2J4 The purpose of treatment of a fistula is to open the fistulous tract across the whole length and to identify the corresponding abnormal anal crypt. Fistulotomy or fistelectomy will be followed in 0% to 68% of cases by a recurrence.7~8Jo~12.13Js The identification of the corresponding crypt is most important in avoiding recurrence.3,8Long-term results are not available. To obtain more insight into the course and long-term results of the treatment, we performed a retrospective study of infants treated with perianal abscess or fistulain-ano in the Pediatric Surgical Center in Nijmegen, The Netherlands. Journa/ofPediat~icSurgery,Vol33,
No 5 (May),
1998: pp 711-713
Netherlands
dren aged 3 years there was soiling one was incontinent
and older were continent for some time. One had during the night.
for feces. constipation
Conc/usions: Simple drainage of a perianal abscess lowed frequently by a fistula. Fistulotomy or fistulectomy fistula-in-ano in infants has a reasonable chance of rence in the short term. Long-term recurrences are tional. There are no serious disabilities in the long run. J Pediatr Surg 33:77 1-713. Copyright o 1998 by WL?. ders Company.
INDEX
WORDS:
perianal
MATERIALS
abscess,
AND
fistula-in-ano,
In two, and
is folof a recurexcepSaun-
infant.
METHODS
The records of all patients treated over a ‘i-year period from January 1974 until December 1994 for perianal abscess or fistula-in-ano were collected and analyzed retrospectively. Only records of infants treated in the first year of life or with a history that started in the first year were studied. In 77 patients, the first presentation dated back to the first year of life. Age distribution is given in Fig 1. In 76% of cases first onset was before the end of the sixth month All patients were boys. In three, the infection settled spontaneously, and the parents of one child refused treatment. There were then 73 patients available for the study. The parents of the selected infants were interviewed by questionnaire with specific questions about the long-term follow-up, especially regarding late complications or recurrences and the final outcome. The parents of 69 of 73 patients returned the questionnaire (81% response rate).
RESULTS
In 72 of the 73 patients, the first sign was a perianal abscess, and only one started as a fistula. Twenty-six patients (36%) had been treated by their general practitioner (mostly abscess incision, frequently several times, with a maximum of nine times). Fourteen patients (19%) had been operated on elsewhere (1 to 4 times) without satisfactory results. At the first admission, 26 patients had a perianal abscess, and in 47 there was a fistula. Six patients had two, and one patient had three fistulae. The location of the From the Pediatric Surgical Cmtel; University Hospital Nijmegen, The Netherlands. Address reprint requests to C. Festen, MD, 413 Pediatric Surgical Centel; PO Box 9101, 6500 HB Nijmegen, The Netherlands. Copyright o 1998 by WB. Saunders Company 0022-3468/98/3305-0009$03.00/O 711
FESTEN
712
Fig 3. 1 Age distribution
3
2
4
5
6
7
8
9
IO
11
Age distribution
of patients
(in months).
abscess or fistula was equally divided between left and right. The abscess was incised and drained, and if possible the connection with the abnormal crypts was laid open. Any fistula was incised over the whole length, with the purpose of identifying the corresponding abnormal crypt. Treatment results are given in Figs 2 and 3. Abscess incision and drainage was followed by a fistula in 35% of cases. In cases in which the corresponding crypt could be identified and was laid open, there were no recurrences. The purpose of treatment of a fistula was to identify the whole canal, from the skin to the abnormal crypt, and incision over its full length. In 25% of cases we could not find the corresponding crypt. The overall recurrence rate was 13%. It made no difference if the abnormal crypt was identified or not. Fistulotomy or fistelectomy made no difference. Nearly all recurrences were immediately after treatment. Long-term follow-up was from 1 to 24 years (mean, 7.7 years). Two children had a late recurrence but healed spontaneously. In one child who had two recurrences, the scar gave some problems with anal cleaning. In another who was also operated on several times, the parents complained about the scar, but in all other cases, the parents were satisfied with the outcome. All children from 3 years of age and older were continent for feces. Two of them had soiling for some time. One had serious problems with constipation, and one was still incontinent for feces at night. DISCUSSION
With few exceptions, fistulae-in-ano in infants are usually of the simple intersphincteric type according to 26 abscesses incision
17 healed
Fig 2.
~.rr!kt
Treatment
ah> L re-incision .L healed
results
for 26 perianal
8 tistulae I second operation .L healed
abscesses.
results
VAN HARTEN
for 47 patients.
12
(n = 77)
Fig 1.
Treatment
AND
Parks et a1.t6 The treatment is therefore simple, dividing the whole length of the fistula without compromising continence. Most cases begin as a perianal abscess. Although spontaneous healing of a perianal abscess is described,7 after incision or spontaneous break through, 35% are followed by a fistula. This is found in this study and in the literature. It seems to make sense to look for a connection with an abnormal crypt during surgical drainage to prevent this recurrence. Division of the fistula was followed in our patients by a 13% recurrence. In the literature this varies from 0 to 68%.7,8JoJ”J3J5Most are small series, and the identification of the corresponding crypt is always quoted as most important to avoid recurrence.7J In our patients, there was no difference in the recurrence rate regardless of whether the abnormal crypt could be identified, but it may still be important to open as much of the fistula as possible. Nothing is known about the natural course of a fistula if it is left untreated. After healing, late recurrences were exceptional and usually minimal. As could be expected, functional results were good, but there may be some compromise of the finishing touch of fecal continence for some time. Scarring may be a problem especially after recurrent incision and may interfere with anal cleaning. Complete incision and drainage of a perianal abscess or fistula in infants is the standard treatment. Careful search for the corresponding abnormal crypt seems important but is not always possible. Normal anal continence does not seem to be in danger. Infantile perianal abscess and fistula-in-ano are very different from those found in adults. REFERENCES 1. Hill JR: Fistulas and fistulous abscesses in the anorectal region: Personal experience in management. Dis Colon Rectum 10:421-434, 1967 2. Matt JG: Anal fistula in infants and children. Dis Colon Rectum 3:258-261, 1960 3. Mazier WP: The treatment and care of anal fistulas: A study of 1,000 patients. Dis Colon Rectum 14:134-144, 1971 4. Duhamel .I: Anal fistulae in childhood. Am J Proctol26:40-43, 1975 5. Fitzgerald RJ, Harding B, Ryan W: Fistula-in-An0 in Childhood: A Congenital Etiology. .I Pediatr Surg 20: 1:80-81, 1985 6. Gianotta A, Alessandrini H: Cryptitis: Cause of p&anal fistulae and abscesses. Ital J Pediatr Surg Sci 7:1-2:25-26, 1993 7. Poenaru D, Yazbeck S: Anal fistula in infants: Etiology, features, management. J Pediatr Surg 28:1194-1195,1993 8. Shafer AD, McGlone TP, Flanagan RA: Abnormal crypts of
PERIANAL
ABSCESS
AND
FISTULA-IN-AN0
Morgagni: The cause of perianal abscess and fistula-in-ano. J Pediatr Surg 22:203-204,1987 9. Takatsuki S: An etiology of anal fistula in infants. Keio J Med 35:1-4,
1976
10. Piazza DJ, Radhakrishnan JMD: Perianal abscess and fistulain-ano in children, Dis Colon Rectum 33:1014-1016, 1990 11. Ventura RC: Fist&in ano in infants. Am .I Surg 86:641-642,1953 12. Al-Salem AH, Laing W, Talwalker V: Fistula-in-ano in infancy and childhood. J Pediatr Surg 29:436-438, 1994
713
13. Grant GS, Al-Salem H, Anim JT, et al: Childhood A clinico-pathological study. Pediatr Surg Int 6:207-209, 14. Abercombie JF, George BD: Perianal Co11 Surg Engl74:385-386, 1992
15. Pople IK, Ralphs 75:904-905,
16. Parks fistula-in-ano.
DNL:
An aetiology
fistula-in-ano: 1991
abscess in children. for fistula
Ann R
in ano. Br J Surg
1988
AG, Gordon PH, Br J Surg 63:1-12,
Hardcastle 1976
JD:
A Classification
of
Abscess and Fistula-in-An0
in Infants
By C. Festen and H. van Hat-ten Nijmegen,
Purpose:The aim of this study was to obtain insight shortand long-term results of treatment of perianal and fistula-in-ano in infants.
The
into the abscess
Methods: This is a retrospective study of the records of patients treated over a 21-year period from January 1974 until December 1994 in a Pediatric Surgical Center. A longterm (1 to 24 year, mean 7.74 year) follow-up by questionaire (response 81%) is also included. Results: Drainage of a perianal abscess is followed in 35% of cases by a fistula. Fistulotomy or fistulectomy is followed in 13% of cases by a recurrence. There were two long-term recurrences that both healed spontaneously. The persisting scar sometimes gives problems with anal cleaning. All chil-
A
PERIANAL ABSCESS and/or fistula-in-ano in infants are more trivial diseases that are seen regularly in a pediatric surgical center. Exact numbers about the frequency are not available. In some large series of patients with perianal fistula reported in the literature 0.5% to 4.3% are children.‘m3 The cases presented here are highly selected as they are in most reports. There is little written in the literature about this problem, and the largest series, of 50 cases, was reported by Duhamel in 1975.4 In childhood, the disease presents in 57% to 86% of casesbefore 1 year of age.4-9There is an overwhelming male preponderance.3%7-11Although the disease starts nearly always as a perianal abscess (18% to 92%),3,5*7J2J3there are many arguments for a congenital origin. Most abscesses and fistulae are located laterally,4 equally divided between left and right.5J3 The usual treatment of a perianal abscess is incision and drainage, but it will be followed in 28% to 85% of cases by a fistula.4J0J2J4 The purpose of treatment of a fistula is to open the fistulous tract across the whole length and to identify the corresponding abnormal anal crypt. Fistulotomy or fistelectomy will be followed in 0% to 68% of cases by a recurrence.7~8Jo~12.13Js The identification of the corresponding crypt is most important in avoiding recurrence.3,8Long-term results are not available. To obtain more insight into the course and long-term results of the treatment, we performed a retrospective study of infants treated with perianal abscess or fistulain-ano in the Pediatric Surgical Center in Nijmegen, The Netherlands. Journa/ofPediat~icSurgery,Vol33,
No 5 (May),
1998: pp 711-713
Netherlands
dren aged 3 years there was soiling one was incontinent
and older were continent for some time. One had during the night.
for feces. constipation
Conc/usions: Simple drainage of a perianal abscess lowed frequently by a fistula. Fistulotomy or fistulectomy fistula-in-ano in infants has a reasonable chance of rence in the short term. Long-term recurrences are tional. There are no serious disabilities in the long run. J Pediatr Surg 33:77 1-713. Copyright o 1998 by WL?. ders Company.
INDEX
WORDS:
perianal
MATERIALS
abscess,
AND
fistula-in-ano,
In two, and
is folof a recurexcepSaun-
infant.
METHODS
The records of all patients treated over a ‘i-year period from January 1974 until December 1994 for perianal abscess or fistula-in-ano were collected and analyzed retrospectively. Only records of infants treated in the first year of life or with a history that started in the first year were studied. In 77 patients, the first presentation dated back to the first year of life. Age distribution is given in Fig 1. In 76% of cases first onset was before the end of the sixth month All patients were boys. In three, the infection settled spontaneously, and the parents of one child refused treatment. There were then 73 patients available for the study. The parents of the selected infants were interviewed by questionnaire with specific questions about the long-term follow-up, especially regarding late complications or recurrences and the final outcome. The parents of 69 of 73 patients returned the questionnaire (81% response rate).
RESULTS
In 72 of the 73 patients, the first sign was a perianal abscess, and only one started as a fistula. Twenty-six patients (36%) had been treated by their general practitioner (mostly abscess incision, frequently several times, with a maximum of nine times). Fourteen patients (19%) had been operated on elsewhere (1 to 4 times) without satisfactory results. At the first admission, 26 patients had a perianal abscess, and in 47 there was a fistula. Six patients had two, and one patient had three fistulae. The location of the From the Pediatric Surgical Cmtel; University Hospital Nijmegen, The Netherlands. Address reprint requests to C. Festen, MD, 413 Pediatric Surgical Centel; PO Box 9101, 6500 HB Nijmegen, The Netherlands. Copyright o 1998 by WB. Saunders Company 0022-3468/98/3305-0009$03.00/O 711
FESTEN
712
Fig 3. 1 Age distribution
3
2
4
5
6
7
8
9
IO
11
Age distribution
of patients
(in months).
abscess or fistula was equally divided between left and right. The abscess was incised and drained, and if possible the connection with the abnormal crypts was laid open. Any fistula was incised over the whole length, with the purpose of identifying the corresponding abnormal crypt. Treatment results are given in Figs 2 and 3. Abscess incision and drainage was followed by a fistula in 35% of cases. In cases in which the corresponding crypt could be identified and was laid open, there were no recurrences. The purpose of treatment of a fistula was to identify the whole canal, from the skin to the abnormal crypt, and incision over its full length. In 25% of cases we could not find the corresponding crypt. The overall recurrence rate was 13%. It made no difference if the abnormal crypt was identified or not. Fistulotomy or fistelectomy made no difference. Nearly all recurrences were immediately after treatment. Long-term follow-up was from 1 to 24 years (mean, 7.7 years). Two children had a late recurrence but healed spontaneously. In one child who had two recurrences, the scar gave some problems with anal cleaning. In another who was also operated on several times, the parents complained about the scar, but in all other cases, the parents were satisfied with the outcome. All children from 3 years of age and older were continent for feces. Two of them had soiling for some time. One had serious problems with constipation, and one was still incontinent for feces at night. DISCUSSION
With few exceptions, fistulae-in-ano in infants are usually of the simple intersphincteric type according to 26 abscesses incision
17 healed
Fig 2.
~.rr!kt
Treatment
ah> L re-incision .L healed
results
for 26 perianal
8 tistulae I second operation .L healed
abscesses.
results
VAN HARTEN
for 47 patients.
12
(n = 77)
Fig 1.
Treatment
AND
Parks et a1.t6 The treatment is therefore simple, dividing the whole length of the fistula without compromising continence. Most cases begin as a perianal abscess. Although spontaneous healing of a perianal abscess is described,7 after incision or spontaneous break through, 35% are followed by a fistula. This is found in this study and in the literature. It seems to make sense to look for a connection with an abnormal crypt during surgical drainage to prevent this recurrence. Division of the fistula was followed in our patients by a 13% recurrence. In the literature this varies from 0 to 68%.7,8JoJ”J3J5Most are small series, and the identification of the corresponding crypt is always quoted as most important to avoid recurrence.7J In our patients, there was no difference in the recurrence rate regardless of whether the abnormal crypt could be identified, but it may still be important to open as much of the fistula as possible. Nothing is known about the natural course of a fistula if it is left untreated. After healing, late recurrences were exceptional and usually minimal. As could be expected, functional results were good, but there may be some compromise of the finishing touch of fecal continence for some time. Scarring may be a problem especially after recurrent incision and may interfere with anal cleaning. Complete incision and drainage of a perianal abscess or fistula in infants is the standard treatment. Careful search for the corresponding abnormal crypt seems important but is not always possible. Normal anal continence does not seem to be in danger. Infantile perianal abscess and fistula-in-ano are very different from those found in adults. REFERENCES 1. Hill JR: Fistulas and fistulous abscesses in the anorectal region: Personal experience in management. Dis Colon Rectum 10:421-434, 1967 2. Matt JG: Anal fistula in infants and children. Dis Colon Rectum 3:258-261, 1960 3. Mazier WP: The treatment and care of anal fistulas: A study of 1,000 patients. Dis Colon Rectum 14:134-144, 1971 4. Duhamel .I: Anal fistulae in childhood. Am J Proctol26:40-43, 1975 5. Fitzgerald RJ, Harding B, Ryan W: Fistula-in-An0 in Childhood: A Congenital Etiology. .I Pediatr Surg 20: 1:80-81, 1985 6. Gianotta A, Alessandrini H: Cryptitis: Cause of p&anal fistulae and abscesses. Ital J Pediatr Surg Sci 7:1-2:25-26, 1993 7. Poenaru D, Yazbeck S: Anal fistula in infants: Etiology, features, management. J Pediatr Surg 28:1194-1195,1993 8. Shafer AD, McGlone TP, Flanagan RA: Abnormal crypts of
PERIANAL
ABSCESS
AND
FISTULA-IN-AN0
Morgagni: The cause of perianal abscess and fistula-in-ano. J Pediatr Surg 22:203-204,1987 9. Takatsuki S: An etiology of anal fistula in infants. Keio J Med 35:1-4,
1976
10. Piazza DJ, Radhakrishnan JMD: Perianal abscess and fistulain-ano in children, Dis Colon Rectum 33:1014-1016, 1990 11. Ventura RC: Fist&in ano in infants. Am .I Surg 86:641-642,1953 12. Al-Salem AH, Laing W, Talwalker V: Fistula-in-ano in infancy and childhood. J Pediatr Surg 29:436-438, 1994
713
13. Grant GS, Al-Salem H, Anim JT, et al: Childhood A clinico-pathological study. Pediatr Surg Int 6:207-209, 14. Abercombie JF, George BD: Perianal Co11 Surg Engl74:385-386, 1992
15. Pople IK, Ralphs 75:904-905,
16. Parks fistula-in-ano.
DNL:
An aetiology
fistula-in-ano: 1991
abscess in children. for fistula
Ann R
in ano. Br J Surg
1988
AG, Gordon PH, Br J Surg 63:1-12,
Hardcastle 1976
JD:
A Classification
of