I have personally performed an internal drainage in 6 patients with high (supraelevator) cryptoglandular perianal abscess. In all 6 patients, The abscess was confirmed on computed tomography and intraoperative anorectal ultrasound sonography. The reason I performed an internal drainage is to prevent the creation of a high fistula. The patients were put on antibiotics for five days. So far no recurrence has been observed. I do agree with you that there is little or no data on this procedure. But it works.

 maybe we should pool data and try to provide some evidence on the efficacy of this procedure



Thank you Peter C Ambe for sharing your experience . What was the follow-up period you have? What happens with the opening in the dentate line? Is the patient left with a residual cavity in the place of the abscess? Do you perform any imaging studies for the patient follow-up?

I agree it's highly interesting to gather data on this technique as there are sporadic cases with apparently good results.

KEY EMPHASIS HERE is perianal abscess inside the anal canal by enlarging the internal opening found at the dentate line.

A few options but avoid direct opening on the dentate line due to a risk of internal sphincter injury and sequelae of faecal incontinence.

Deroofing the cavity above the dentate line for proper drainage,(under Direct vision or Endoscopically);

Then a thorough or copious irrigation /lavage and application of draining seton follow-up with repeated sitz bath + antibiotic coverage. Patient is admitted initially for a few days and discharged to be seen weekly for 2-3months.

Once the internal opening is not closed in that period then

The other second option is surgical closure of the opening using different flap closure technique -Three of these were 1) advancement flaps - mucosa-submucosa flap (MSAF), 2)rectal wall advancement flap (RWAF), 3) anocutaneous advancement

flap (ACAF). The last approach was direct closure of the internal

opening. The flaps were constructed about 2 to 3 months following

abscess drainage and Seton placement in the patients.

Thanks for the good question.

This is a major error commonly committed by Untrained personnel.

And a key area of challenge with Anal abscess drainage.

Thanks

Bamidele Johnson Alegbeleye, thank you for your contribution. I'm asking about drainage of an abscess through the dentate line, not a supralevator or extrasphincteric abscess.

In these cases there is no external opening (fistulus tract) and I have not found any data concerning the evolution of the abscess residual cavity or the drainage opening at the dentate line. I've had experience with the Endosponge for healing of anastomotic rectal fistulas but the cases I've sporadically seen mentioned do not use any material to pack the abscess cavity.

To me any residual cavity in the intersphincteric space or the ischiorectal fossa would be a major risk factor for abscess recurrence or anorectal fistula.

I have done a few cases - drained by enlarging the internal opening. Most of them had good relief, at least short term. I have not done imaging routinely in the postop. follow up of these patients.

One young boy presented after a few months with bleeding PR. He had a granuloma/pseudopolyp at the opening and imaging showed an inter sphincteric tract. This was excised and sinus curetted. Now he is asymptomatic and on follow-up. Another patient, who was a diabetic had residual induration on follow-up and was readmitted and had settled with antibiotics. Sorry,I do not have long term follow-up data of the patients.

I place the internal opening above the dentate line to prevent the development of a fistula. In uneventful cases ( no fever, drop in inflammatory markers like WBC and CRP) i go for endorectal ultrasound after 2 Weeks. Otherwise i order a ct scan as needed.

Did you mean submucosal abscess?