Perianal abscess is an acute purulent infection of the soft tissues around the rectum and the perianal canal and its surrounding space, and is one of the common and frequent diseases in anorectal surgery, concentrating on young and middle-aged men aged 20-40 years old, and also sometimes on infants and children, pregnant women and elderly people with weak resistance. The more recognized cause is the theory of anal sinus and anal gland infection proposed by scholars such as Eisenhammer and Paco, which emphasizes the significance of the anal gland and divides perianal abscess into “glandular abscess” and “non-glandular abscess”, which has a significant impact on the diagnosis, treatment and prognosis of perianal abscess. The classification of perianal abscess into “adenogenic abscess” and “non-adenogenic abscess” has certain guiding significance for the diagnosis, treatment and prognosis of perianal abscess. Nowadays, most clinics classify perianal abscesses into “low abscess” and “high abscess” according to the 1995 standard of the national Chinese medicine industry, using the anal raphe as the boundary, and surgery is considered to be the most effective treatment for them. According to the specific situation of abscess, there are various choices of surgical methods, and the following methods are mainly used in clinical treatment of perianal abscess: Wang Xiaolong, Department of Surgery, People’s Hospital of Lu’an
1.1 Traditional surgery.
Simple incision and drainage and one-time incision and curettage, both of which are more basic and traditional methods of treating perianal abscess. After lumbar anesthesia or local anesthesia, the patient is placed in a lithotomy position, and an arc-shaped incision or a radial incision is made at the most obvious place of abscess fluctuation, and after thorough drainage of pus, the pus space is fully separated and no dead space is left to facilitate postoperative drainage. One-time radical incision and cure is based on the incision and drainage of pus, and it is necessary to carefully search for the internal opening near the infected anal sinus and anal gland, and incise the tissue between the internal opening and the pus cavity incision to thoroughly remove the necrotic tissue in the cavity and achieve the purpose of radical cure. Macfie et al [1] concluded that simple incision and drainage without blindly destroying the normal perianal tissues and anatomy is the safest procedure for most perianal abscesses, and Abercrombie et al [2] similarly concluded that simple incision and drainage is safer for perianal abscesses in children. With the introduction of the theory of anal gland infection, perianal abscesses have been clinically classified into “glandular” and “non-glandular”. Some scholars believe that simple incision and drainage has a high cure rate for “non-glandular perianal abscess”, while for “glandular perianal abscess”, the internal opening needs to be searched and treated in order to achieve radical cure. The rate of recurrence or fistula formation after incision and drainage alone has been shown to be as high as 90% [3]. One-time incision and curettage is more often used for low perianal abscesses, and Liu et al [4] used this method to treat perianal abscesses with a 98.5% recovery rate, with no recurrence or fistula formation and no anal incontinence detected at postoperative follow-up. In the case of low perianal abscesses, the internal opening is easily accessible due to its low location, and it is possible to avoid damaging the anorectal ring while completely incising the internal opening, resulting in a higher clinical cure rate. For high-grade perianal abscess, a one-time incision and cure will destroy too many perianal anatomical structures and affect the postoperative anal function.
1.2 Various thread hanging techniques:
Thread hanging therapy for perianal abscesses has a long history and has been described in Chinese medicine for a long time, and more detailed treatment techniques such as “finishing the root and boiling the thread, hanging through the large intestine” and “falling lead and spitting suspension” have been proposed in the Complete Book of Ancient and Modern Medicine, and the mechanism and postoperative recovery records are clear[5] . The mechanism and postoperative recovery records are clear[5] . With the further understanding of perianal anatomy in modern medicine, more and more scholars have begun to pay attention to the recovery of the fine functions of the anus in patients with perianal abscesses after surgery. The use of
The one-time treatment of perianal abscess by hanging wire therapy makes use of the foreign body stimulation and chronic cutting function of hanging wire to make the tissues between the internal orifice and the anal margin go through the process of chronic cutting and adhesion growth with the surrounding tissues. The hanging wire also has a certain drainage and marking effect, which is more convenient when changing medication and flushing the abscess cavity early after surgery. In recent years, many experts and scholars have used various hanging wires and their modified techniques to treat high perianal abscesses with good results, and the main methods are.
1.2.1 Cutting and hanging (real) wire: that is, after cutting and draining the pus and thoroughly removing the pus cavity, carefully finding the inner mouth, hanging a rubber band from the inner mouth with a probe, cutting the skin and subcutaneous tissues between the inner mouth and the anal verge, closing the two ends of the rubber band and ligating it loosely and tightly. This method is used to treat the internal orifice while performing chronic cutting with a wire instead of a knife, which not only avoids the possibility of patients facing secondary surgery after traditional incision and drainage, reduces patients’ surgical pain and economic burden, but also protects the function of the anal sphincter to a certain extent and improves the prognosis. Guan Weiyu et al [6] applied incision and hanging wire to perform radical treatment on 80 patients with high perianal abscess, and the cure rate reached 95%, and no recurrence and functional disorders were seen in the follow-up, which is worth promoting and applying in the clinic because of its high cure rate, simple operation, few postoperative complications, and good protection of anal function for high perianal abscess. Guo Yun et al [7] believed that for perianal abscesses with deep pus cavity location and more complicated perianal abscesses, the postoperative recurrence rate of this procedure is high, and the importance of internal opening search, unobstructed drainage and postoperative care should not be ignored.
1.2.2 Directional cutting and hanging (real) wire: Chen Yugen et al [8] studied the cutting and hanging wire from the biomechanical point of view, and concluded that the rubber band hanging wire cut the hanging tissue from all around to the center at the same time, which was not only painful for the patient but also could not achieve the cutting purpose of “secluded place that is mending” and would increase the damage to the anal function. The directional hanging technique is proposed, in which a tough skin pad is placed under the hanging tissues, so that the rubber band can produce a directional force that cuts only in the direction of the anal canal, achieving the purpose of cutting and growing the hanging tissues in the deep part and the base first. The directional hanging technique has certain advantages in reducing the patient’s pain and protecting the anal function and reducing postoperative recurrence.
1.2.3 Shallow hanging wire: A major feature of traditional cutting and hanging wire is to hang the wire only in the highest part of the abscess cavity, with the purpose of complete patency and drainage. However, when hanging wires are performed in many high-grade perianal abscesses, the operation is difficult and more tissues are hung into them, and the patients have severe pain after tightening the wires, which is more damaging to the perianal muscles and is easily complicated by anal overflow, fecal overflow and even incomplete incontinence after surgery. Chen Yugen et al [9] combined the advantages and disadvantages of the traditional hanging technique and proposed shallow hanging technique, which reduced the height of the hanging wire without affecting the drainage effect, and conducted a randomized controlled study on 60 patients with high perianal abscess. As a result, there was no significant difference in the cure rate compared with the traditional hanging method, while the degree of perianal injury was significantly reduced and the postoperative anal function was better protected, which to a certain extent reduced the operational difficulty and alleviated the patient’s pain. Zhang Dan et al [10] also concluded that the shallow hanging technique could better avoid the damage to the sphincter muscle by traditional hanging, and they treated 40 patients with perianal abscesses with shallow hanging therapy and achieved satisfactory results. Xia Mingjin [11] used the shallow hanging technique to treat high perianal abscesses and also achieved satisfactory results.
1.2.4 Drainage hanging (dummy) wire: The so-called hanging dummy wire is proposed for the protection of anal sphincter, which transforms the cutting effect of traditional hanging wire on sphincter and other hanging-in tissues into the marking and pus cavity drainage effect. Zhu Bingyi [12] believed that the only way to ensure intact postoperative anal function is to strictly avoid damage to the anal sphincter. Qian Haihua et al [13] used the dummy hanging wire drainage method on the dentate line to treat 10 cases of sciatic rectal fossa abscess and found that the dummy hanging wire drainage method did not reduce the cure rate and had the advantages of fewer postoperative complications and less pain in patients due to the traditional procedure in terms of anal function protection. Gong et al [14] treated 28 cases of high perianal abscesses with low incision and high virtual hanging wire method, and all of them were cured with one-time eradication while protecting the anal sphincter intact, with less trauma and postoperative complications. Bai Donglin et al [15] treated 124 cases of high hoof type perianal abscesses with the dummy hanging wire drainage technique and reached the same conclusion.
1.2.5 Other modified hanging wire techniques: With the use of hanging wire techniques in clinical practice, scholars have continuously improved them, including counter-oral incision with dragging wire [16], incisional double hanging wire drainage [17], hanging medicine wire [18], and nudging flap hanging wire [19], all of which have achieved satisfactory results.
1.3 Procedures focusing on drainage of the abscess cavity and postoperative wound healing: various drainage techniques
In the whole treatment process of perianal abscess, whether the drainage is unobstructed or not has been considered as an important factor affecting the success of the operation, and Onaca et al [20] concluded that ensuring unobstructed postoperative trauma drainage of perianal abscess can reduce postoperative recurrence and improve the success rate of the operation. In recent years, many scholars have studied different methods for the unobstructed drainage of different types of perianal abscesses, mainly including.
1.3.1 Multi-incisional counter-oral drainage: this method is mainly based on the traditional incisional drainage, and for abscesses with a large range of abscess cavities, it is not necessary to completely incise the affected skin and use overwidening, and it is sufficient to adopt taking multiple incisions to ensure the unobstructed drainage between incisions. It has the advantages of less traumatic damage, less patient pain, and faster postoperative healing. Zhu Tianzheng et al [21] performed multi-incisional para-oral drainage of deep perianal multi-gap abscess for one-stage radical treatment in a total of 50 patients, with an average healing time of 30 d after surgery and a follow-up of 5 years, with one case of recurrence and no recurrence or complications seen in the rest. Fu Hao et al [22] used multi-incisional floating line drainage technique to treat 30 patients with high-grade multiple interstitial abscesses and achieved satisfactory results, and the study concluded that multi-incisional counter-oral drainage is simple to operate and in line with the development trend of modern surgery.
1.3.2 Intralesional tube drainage: This method is to drain the abscess cavity by placing a latex tube with a multi-lateral hole corresponding to the size of the abscess cavity, so that the drainage of high abscess cavity or complex abscess cavity is more smooth and more conducive to the growth of granulation after surgery. Lai Ridong et al [23] treated 30 cases of high-grade perianal abscesses with fixed drainage tubes, which resulted in shorter healing time and significantly lower postoperative pain and anal incontinence compared with the traditional procedure. Zhang Bei et al [24] treated 48 cases of high perianal abscesses with homemade double cannula drainage using silicone drainage tubes and skin strips, which also reduced trauma, accelerated healing, better protected anal function, and was economical and practical.
1.3.3 Addition of negative pressure device for drainage: In recent years, the concept of negative pressure wound therapy (NPWT) has been gradually applied to the treatment of perianal abscesses, transforming the traditional passive drainage of postoperative pus cavities into active drainage, and has been proven to have the effects of increasing trauma blood flow, reducing exudation, and suppressing bacteria, which is an effective new treatment method. Zheng Weiqin et al [25] used negative pressure ball drainage to treat high-grade perianal abscess and achieved satisfactory results, with the purpose of “zero accumulation” of drainage and the effects of promoting healing, pain relief and anti-infection. Jiang Qingtong [26] used this method to treat 69 cases of high perianal abscesses and also achieved remarkable results. An Kexiang et al [27] made their own negative pressure vacuum bottle using an infusion set and glass saline bottles to treat 30 cases of high perianal abscesses, which reduced patients’ pain and hospitalization time while ensuring the cure rate, reflecting the advantages of negative pressure treatment.
1.4 New technology-assisted treatment of perianal abscess
With the development of medical technology and science, more and more new technologies have been applied to the surgery and adjuvant treatment of perianal abscess, promoting the improvement of perianal abscess treatment from all aspects. For example, ultrasound, CT, MR and other techniques in imaging are good guides for the diagnosis of perianal abscess, the search for the internal opening and the judgment of the surgical procedure [28]. High-frequency capacitive field makes intraoperative operation of perianal abscess easier and less intraoperative bleeding [29]. Hyperbaric oxygen technology plays a role in the treatment of perianal abscesses to promote wound healing and reduce inflammatory reactions [30]. The application of bio-occlusive materials provides a new direction for the treatment of perianal abscesses [31]. In addition, some Chinese herbal medicines have been used topically to drain pus and create muscle in postoperative trauma of perianal abscesses [32].
At present, surgery is still the main treatment for perianal abscesses, and different surgical approaches are adopted clinically for different types of abscesses in various ways. Scholars have continuously improved and researched various aspects such as the treatment of the internal opening, the way of hanging wires, the way of drainage and wound healing to adopt appropriate surgical methods for various perianal abscesses, striving to achieve cure and avoid recurrence during the treatment process, while minimizing damage to the perianal anatomy and protecting the anal function. The continuous improvement of various surgical procedures and the use of new techniques have led to some progress in the treatment of perianal abscesses, with greater progress in the treatment of the more simple low-level perianal abscesses.
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