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A systematic review and meta-analysis of the use of packing in the management of perianal abscesses.Annals of the Royal College of Surgeons... Apr 2024Perianal abscesses are common presentations and reasons for emergency general surgery admissions. Management involves incision and drainage of the abscess and packing...
BACKGROUND
Perianal abscesses are common presentations and reasons for emergency general surgery admissions. Management involves incision and drainage of the abscess and packing the cavity with internal wound dressings. This meta-analysis aimed to assess in adults if packing an abscess or leaving it unpacked leads to a significant difference in the outcomes of pain on wound dressing, time to healing, rate of fistulation and abscess recurrence.
METHODS
Randomised controlled trials (RCTs) with participants aged 18 years or older that compared packing of perianal abscess cavities with no packing between 2002 and 2022 were searched for in December 2022 on OVID Medline and Embase, the CENTRAL register of trials, PubMed and Google Scholar. Risk of bias was assessed using the Cochrane Risk of Bias tool. Random effects meta-analysis was conducted on the data extracted.
RESULTS
Three RCTs involving 490 patients were analysed for the outcomes of abscess recurrence and postoperative fistula formation; the data were not adequate to assess pain on dressing and time to healing. For unpacked versus packed, the pooled relative risk of abscess recurrence was 1.57 (95% confidence interval (CI) 0.764, 3.29, =0.219) and for fistula formation 0.686 (95% CI 0.430, 1.09, =0.114). These results suggest there is no significant benefit to packing abscess cavities.
CONCLUSIONS
Analysis of the outcomes suggests there is no significant difference with regards to rates of abscess recurrence or fistula formation between the packed and unpacked groups; however, appropriately powered RCTs are required in this area to provide more primary evidence to inform best practice and clinical management.
PubMed: 38563064
DOI: 10.1308/rcsann.2023.0108 -
Annals of Gastroenterology 2024Managing complex perianal fistulizing Crohn's disease (CD) remains challenging, despite current medical and surgical treatment approaches. Darvadstrocel, a therapy...
BACKGROUND
Managing complex perianal fistulizing Crohn's disease (CD) remains challenging, despite current medical and surgical treatment approaches. Darvadstrocel, a therapy utilizing adipose-derived stem cells, shows promise in promoting tissue regeneration and healing, offering a novel and effective treatment for fistula management.
METHOD
A systematic literature search was conducted on PubMed and Scopus to identify studies involving patients with complex perianal fistulizing CD treated with darvadstrocel.
RESULTS
In total, 2 randomized controlled trials (RCT), 5 observational studies with retrospective data collection and 2 observational studies with prospective design were included in the final review. Data from the European ADMIRE-CD RCT demonstrated that darvadstrocel is superior to placebo in terms of clinical and imaging improvement over both the short and long term. These findings align with the prospective studies analyzed in this systematic review. The rate of treatment-emergent adverse events in the ADMIRE-CD trial's RCTs was similar in both the darvadstrocel and control groups, with perianal abscess being the most common adverse event up to 52 weeks after drug administration. Retrospective studies indicated no side-effects beyond 52 weeks.
CONCLUSIONS
Darvadstrocel appears to be a new, potentially effective and safe treatment option for the management of complex perianal fistulas. However, more randomized clinical trials are needed to evaluate the efficacy and safety profile of the drug.
PubMed: 38223244
DOI: 10.20524/aog.2023.0850 -
Postepy Dermatologii I Alergologii Jun 2023Hidradenitis suppurativa (HS) is a chronic disease which is often recurrent and occurs as abscesses of the apocrine gland. The most common locations of HS are... (Review)
Review
Hidradenitis suppurativa (HS) is a chronic disease which is often recurrent and occurs as abscesses of the apocrine gland. The most common locations of HS are gluteal/perianal, axillary or inguinal. It is reasonable to assume that squamous cell carcinoma may arise from HS. As researchers in the field of dermatology, HS surgery and conventional surgical oncology, we studied whether there is any correlation between HS and neoplasms. Evidence shows a correlation between HS and squamous cell carcinoma. The aim of the study was to find literature about HS and SCC and analyse potential risk factors. This is a systemic review concerning squamous cell carcinoma and hidradenitis suppurativa.
PubMed: 37545826
DOI: 10.5114/ada.2023.126563 -
European Journal of Pediatric Surgery :... Jun 2024This systematic review and meta-analysis of nonrandomized studies (NRSs) aimed to evaluate the clinical efficacy and safety of two types of surgical interventions... (Meta-Analysis)
Meta-Analysis Comparative Study
This systematic review and meta-analysis of nonrandomized studies (NRSs) aimed to evaluate the clinical efficacy and safety of two types of surgical interventions (respectively drainage alone and drainage with primary fistula treatment) for perianal abscesses (PAs) in children. Studies from 1992 to July 2022 were searched in 10 electronic databases. All relevant NRSs with available data which compared surgical drainage with or without primary fistula treatment were included. Patients with underlying diseases which led to abscess formation were excluded. The Newcastle-Ottawa Scale was used to assess the risk of bias and quality of the included studies. The outcomes were the healing rate, fistula formation rate, fecal incontinence, and wound healing duration. A total of 16 articles with 1,262 patients were considered suitable for the final meta-analysis. Primary fistula treatment was associated with a significantly higher healing rate when compared with incision and drainage alone (odds ratio [OR]: 5.76, 95% confidence interval [CI]: 4.04-8.22). This aggressive procedure for PA resulted in an 86% reduction in the fistula formation rate (OR: 0.14, 95% CI: 0.06-0.32). Limited data showed patients who underwent primary fistula treatment have a minor effect on postoperative fecal incontinence. Primary fistula treatment demonstrates a better clinical efficacy in promoting the healing rate and decreasing the formation of fistulas in PAs in children. The available evidence for a minor impact on anal function after this intervention is less strong.
Topics: Humans; Drainage; Child; Abscess; Rectal Fistula; Anus Diseases; Fecal Incontinence; Treatment Outcome; Wound Healing
PubMed: 37023788
DOI: 10.1055/a-2070-3613 -
Inflammatory Bowel Diseases Oct 2022Perianal Crohn's disease (pCD) is a potentially severe phenotype of CD. We conducted a systematic review with meta-analysis to estimate cumulative incidence, risk... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND AIMS
Perianal Crohn's disease (pCD) is a potentially severe phenotype of CD. We conducted a systematic review with meta-analysis to estimate cumulative incidence, risk factors, and outcomes of pCD in population-based cohort studies.
METHODS
Through a systematic literature review through March 1, 2021, we identified population-based inception cohort studies reporting cumulative incidence of perianal disease (primarily abscess and/or fistula) in patients with CD. We estimated the cumulative incidence of pCD at presentation and 1-, 5-, and 10-year follow-up, and risk factors for perianal disease and outcomes including risk of major (bowel resection, proctectomy, ostomy) and minor perianal (incision and drainage, seton placement, etc.) surgery.
RESULTS
In 12 population-based studies, prevalence of pCD was 18.7% (95% confidence interval [CI], 12.5%-27.0%) with 1-, 5-, and 10-year risk of perianal disease being 14.3% (95% CI, 7.9%-24.6%), 17.6% (95% CI, 11.3%-26.5%), and 18.9% (95% CI, 15.0%-23.4%), respectively. Approximately 11.5% of patients (95% CI, 6.7%-19.0%) had perianal disease at or before CD diagnosis. Colonic disease location and rectal involvement were associated with higher risk of pCD. Overall, 63.3% of patients (95% CI, 53.3-72.3) required minor perianal surgery and 6.4% of patients (95% CI, 1.8%-20.6%) required major abdominal surgery for pCD. Use of biologic therapy for pCD is common and has steadily increased throughout the years.
CONCLUSIONS
Approximately 1 in 5 patients with CD develops perianal disease within 10 years of CD diagnosis, including 11.5% who have perianal disease at presentation. Approximately two-thirds of patients require perianal surgery, with a smaller fraction requiring major abdominal surgery.
Topics: Cohort Studies; Crohn Disease; Humans; Incidence; Proctectomy; Rectal Fistula; Treatment Outcome
PubMed: 34792604
DOI: 10.1093/ibd/izab287 -
Annals of Palliative Medicine Sep 2021Surgery is the clinically preferred treatment for high perianal abscesses. Incision and seton drainage improve the cure rate and reduce recurrence. We aimed to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Surgery is the clinically preferred treatment for high perianal abscesses. Incision and seton drainage improve the cure rate and reduce recurrence. We aimed to systematically evaluate the clinical effect and safety of incision and seton drainage in the treatment of high perianal abscess.
METHODS
China Knowledge Network (CNKI), WanFang database, VIP database, PubMed, and Cochrane Library were searched and all relevant Chinese and English language documents until July 2021were retrieved. All records that described randomized clinical trials (RCTs) of incision and seton drainage for the treatment of high perianal abscess were eligible. Documents that met the inclusion criteria were evaluated for bias using the Cochrane Collaboration Risk Evaluation Standard, and Revman5.4 software was used to analyze the data.
RESULTS
Fourteen RCTs were included. The results of nine studies showed that the clinical cure rate of the incision-seton group was higher than that of the incision-drainage group (P<0.05). Seven studies showed that the wound healing time of the incision-seton group was shorter than that of the incision-drainage group (P<0.05). Four studies showed that the visual analogue scale (VAS) score of the incision-seton group was lower than that of the incision-drainage group (P<0.05). Five studies showed that the Wexner score of the incision-seton group was lower than that of the incision-drainage group (P<0.05). Six studies showed that the formation rate of anal fistula in the incision-seton group was lower than that in the incision-drainage group (P<0.05). Six studies demonstrated that the recurrence rate of abscess in the incision-seton group was lower than that in the incision-drainage group (P<0.05). Seven studies showed that the incidence of adverse events in the incision-seton group was lower than that in the incision-drainage group (P<0.05). Five studies demonstrated that the length of stay in the incision-seton group was shorter than that of the incision-drainage group (P<0.05).
DISCUSSION
The choice of surgical methods in clinical research has always been controversial. The incision-seton method can effectively and safely treat high perianal abscess. However, the results of this meta-analysis still leave some gaps in the evidence. More large-sample, high-quality, and multi-center RCTs are needed.
Topics: Abscess; Anus Diseases; Drainage; Humans; Rectal Fistula; Recurrence
PubMed: 34628909
DOI: 10.21037/apm-21-2229 -
Clinical and Experimental Immunology Apr 2019Collaboration between gastroenterologists and rheumatologists is recommended for the correct management of patients with associated spondyloarthritis (SpA) and...
Collaboration between gastroenterologists and rheumatologists is recommended for the correct management of patients with associated spondyloarthritis (SpA) and inflammatory bowel disease (IBD). We aimed to establish the appropriateness of several red flags for a prompt specialist referral. A systematic review of the literature was performed using the GRADE method to describe the prevalence of co-existing IBD-SpA and the diagnostic accuracy of red flags proposed by a steering committee. Then, a consensus among expert gastroenterologists and rheumatologists (10 in the steering committee and 13 in the expert panel) was obtained using the RAND method to confirm the appropriateness of each red flag as 'major' (one sufficient for patient referral) or 'minor' (at least three needed for patient referral) criteria for specialist referral. The review of the literature confirmed the high prevalence of co-existing IBD-SpA. Positive and negative predictive values of red flags were not calculated, given the lack of available data. A consensus among gastroenterology and rheumatology specialists was used to confirm the appropriateness of each red flag. Major criteria to refer patients with SpA to the gastroenterologist included: rectal bleeding, chronic abdominal pain, perianal fistula or abscess, chronic diarrhoea and nocturnal symptoms. Major criteria to refer patients with IBD to the rheumatologist included: chronic low back pain, dactylitis, enthesitis and pain/swelling of peripheral joints. Several major and minor red flags have been identified for the diagnosis of co-existing IBD-SpA. The use of red flags in routine clinical practice may avoid diagnostic delay and reduce clinic overload.
Topics: Abdominal Pain; Consensus; Diarrhea; Disease; Expert Testimony; Gastroenterologists; Hemorrhage; Humans; Inflammatory Bowel Diseases; Practice Guidelines as Topic; Prevalence; Rectum; Referral and Consultation; Rheumatologists; Spondylitis, Ankylosing
PubMed: 30554407
DOI: 10.1111/cei.13246 -
Ultraschall in Der Medizin (Stuttgart,... Jun 2017Transperineal ultrasound (TPUS) is a practical tool for assessing perianal inflammatory lesions. We systematically review its accuracy for detecting and classifying... (Comparative Study)
Comparative Study Meta-Analysis Review
Transperineal ultrasound (TPUS) is a practical tool for assessing perianal inflammatory lesions. We systematically review its accuracy for detecting and classifying perianal fistulae and abscesses. The National Library of Medicine and Embase were searched for articles on TPUS for the assessment of idiopathic and Crohn's perianal fistulae and abscesses. Two reviewers independently reviewed eligible studies and rated them for quality using the QUADAS tool. The primary outcome measure was the accuracy of TPUS as measured by its sensitivity and positive predictive value (PPV) in detecting and classifying perianal fistulae, internal openings and perianal abscesses. We included 12 studies (565 patients). Overall, the methodological quality of the studies was suboptimal. 3 studies were retrospective and 4 showed significant risks of bias in the application of the reference standard. The sensitivity of TPUS in detecting perianal fistulae on a per-lesion basis was 98 % (95 % CI 96 - 100 %) and the PPV was 95 % (95 % CI 90 - 98 %). The detection of internal openings had a sensitivity of 91 % (95 % CI 84 - 97 %) with a PPV of 87 % (95 % CI 76 - 95 %). The classification of fistulae yielded a sensitivity of 92 % (95 % CI 85 - 97 %) and a PPV of 92 % (95 % CI 83 - 98 %). TPUS had a sensitivity of 86 % (95 % CI 67 - 99 %) and PPV of 90 % (95 % CI 76 - 99 %) in the detection of perianal abscesses. The current literature on TPUS illustrates good overall accuracy in the assessment of perianal fistulae and abscesses. However, many studies had methodological flaws suggesting that further research is required.
Topics: Abscess; Adolescent; Adult; Aged; Aged, 80 and over; Anus Diseases; Child; Child, Preschool; Endosonography; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Rectal Fistula; Retrospective Studies; Sensitivity and Specificity; Treatment Outcome; Young Adult
PubMed: 28399604
DOI: 10.1055/s-0043-103954 -
The Cochrane Database of Systematic... Aug 2016A perianal abscess is a collection of pus under the skin, around the anus. It usually occurs due to an infection of an anal gland. In the UK, the annual incidence is 40... (Review)
Review
BACKGROUND
A perianal abscess is a collection of pus under the skin, around the anus. It usually occurs due to an infection of an anal gland. In the UK, the annual incidence is 40 per 100,000 of the adult population, and the standard treatment is admission to hospital for incision and drainage under general anaesthetic. Following drainage of the pus, an internal dressing (pack) is placed into the cavity to stop bleeding. Common practice is for community nursing teams to change the pack regularly until the cavity heals. Some practitioners in the USA and Australia make a small stab incision under local anaesthetic and place a catheter into the cavity which drains into an external dressing. It is removed when it stops draining. Elsewhere in the USA, simple drainage is performed in an outpatient setting under local anaesthetic.
OBJECTIVES
To assess the effects of internal dressings in healing wound cavities resulting from drainage of perianal abscesses.
SEARCH METHODS
In May 2016 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL Plus. We also searched clinical trial registries to identify ongoing and unpublished studies, and searched reference lists of relevant reports to identify additional studies. We did not restrict studies with respect to language, date of publication, or study setting.
SELECTION CRITERIA
Published or unpublished randomised controlled trials (RCTs) comparing any type of internal dressing (packing) used in the post-operative management of perianal abscess cavities with alternative treatments or different types of internal dressing.
DATA COLLECTION AND ANALYSIS
Two review authors independently performed study selection, risk of bias assessment, and data extraction.
MAIN RESULTS
We included two studies, with a total of 64 randomised participants (50 and 14 participants) aged 18 years or over, with a perianal abscess. In both studies, participants were enrolled on the first post-operative day and randomised to continued packing by community district nursing teams or to no packing. Participants in the non-packing group managed their own wounds in the community and used absorbant dressings to cover the area. Fortnightly follow-up was undertaken until the cavity closed and the skin re-epithelialised, which constituted healing. For non-attenders, telephone follow-up was conducted.Both studies were at high risk of bias due to risk of attrition, performance and detection bias.It was not possible to pool the two studies for the outcome of time to healing. It is unclear whether continued post-operative packing of the cavity of perianal abscesses affects time to complete healing. One study reported a mean time to wound healing of 26.8 days (95% confidence interval (CI) 22.7 to 30.7) in the packing group and 19.5 days (95% CI 13.6 to 25.4) in the non-packing group (it was not clear if all participants healed). We re-analysed the data and found no clear difference in the time to healing (7.30 days longer in the packing group, 95% CI -2.24 to 16.84; 14 participants). This was assessed as very low quality evidence (downgraded three levels for very serious imprecision and serious risk of bias). The second study reported a median time to complete wound healing of 24.5 days (range 10 to 150 days) in the packing group and 21 days (range 8 to 90 days) in the non-packed group. There was insufficient information to be able to recreate the analysis and the original analysis was inappropriate (did not account for censoring). This second study also provided very low quality evidence (downgraded four levels for serious risk of bias, serious indirectness and very serious imprecision).There was very low quality evidence (downgraded for risk of bias, indirectness and imprecision) of no difference in wound pain scores at the initial dressing change. Both studies also reported patients' retrospective judgement of wound pain over the preceding two weeks (visual analogue scale, VAS) as lower for the non-packed group (2; both studies) compared with the packed group (0; both studies); (very low quality evidence) but we have been unable to reproduce these analyses as no variance data were published.There was no clear evidence of a difference in the number of post-operative fistulae detected between the packed and non-packed groups (risk ratio (RR) 2.31, 95% CIs 0.56 to 9.45, I(2) = 0%) (very low quality evidence downgraded three levels for very serious imprecision and serious risk of bias).There was no clear evidence of a difference in the number of abscess recurrences between the packed and non-packed groups over the variable follow-up periods (RR 0.72, 95% CI 0.22 to 2.37, I(2) = 0%) (very low quality evidence downgraded three levels for serious risk of bias and very serious imprecision).No study reported participant health-related quality of life/health status, incontinence rates, time to return to work or normal function, resource use in terms of number of dressing changes or visits to a nurse, or change in wound size.
AUTHORS' CONCLUSIONS
It is unclear whether using internal dressings (packing) for the healing of perianal abscess cavities influences time to healing, wound pain, development of fistulae, abscess recurrence or other outcomes. Despite this absence of evidence, the practice of packing abscess cavities is commonplace. Given the lack of high quality evidence, decisions to pack may be based on local practices or patient preferences. Further clinical research is needed to assess the effects and patient experience of packing.
Topics: Abscess; Anus Diseases; Bandages; Drainage; Humans; Postoperative Complications; Randomized Controlled Trials as Topic; Rectal Fistula; Self Care; Time Factors; Wound Healing
PubMed: 27562822
DOI: 10.1002/14651858.CD011193.pub2 -
Health Technology Assessment... 2001Most surgically sutured wounds heal without any complication. However, in some cases wound healing can be delayed due to the presence of infection or wound breakdown.... (Review)
Review
BACKGROUND
Most surgically sutured wounds heal without any complication. However, in some cases wound healing can be delayed due to the presence of infection or wound breakdown. This can result in the wounds becoming cavity wounds and thus necessitate healing by secondary intention. Other surgical wounds that are not sutured but left to heal by secondary intention include abscess cavities such as perianal abscesses or breast abscesses. Surgical wounds healing by secondary intention are thought to heal more slowly than wounds healing by primary intention, especially if infection is present or healing is compromised by factors such as decreased blood supply, poor nutritional status or a general suppression of the immune response. Such wounds may contain dead tissue and have a moderate or high level of exudate. Debridement involves the removal of devitalised, necrotic tissue or fibrin from a wound. There are many different methods that can be used to debride a wound, which are broadly classified as surgical/sharp, biosurgical, mechanical, chemical, enzymatic and autolytic. Although it is generally agreed that the management of surgical wounds which contain devitalised tissue and are healing by secondary intention requires debridement, it is not always clear as to what is the best method or agent to use. There is currently a large selection of products with debriding properties available on the market, which vary considerably in cost. It is important that the choice of both debriding method and product is based on the best scientific evidence available, taking into account both cost and effectiveness data.
OBJECTIVES
The review had two main objectives: (1) To determine the clinical effectiveness and cost-effectiveness of debriding agents in treating surgical wounds healing by secondary intention. (2) To evaluate the clinical effectiveness and cost-effectiveness of treating patients with surgical wounds healing by secondary intention at specialised wound care clinics as compared to conventional care. The review incorporated all debriding methods and any agent that is considered to have a debriding property. METHODS The following databases were searched using strategies designed specifically for each database: MEDLINE, EMBASE, CINAHL, HMIC (Health Management Information Consortium), CCTR via the Cochrane Library, the National Research Register (NRR), the NHS Economic Evaluation Database (NHS EED), and the Health Economic Evaluations Database (HEED). Additional references were identified through reviewing manufacturer and sponsor submissions made to NICE, the bibliographies of retrieved articles, and conferences proceedings on the Internet. Only randomised controlled trials (RCTs) or non-randomised controlled trials with concurrent controls and full economic evaluations were considered for inclusion. Only studies that evaluated some sort of debriding method or a specialised wound care clinic (a nurse with specialist training in wound care; care being provided by a multidisciplinary team; a fast-track referral system to other professions (e.g. dermatologist); or access to the latest health technology) were included in the review. Studies had to include participants with surgical wounds healing by secondary intention (e.g. cavity wounds, the consequences of wound dehiscence and abscesses) and report an objective measure of wound healing. Data were extracted by one reviewer and checked by a second. Quality assessment was conducted independently by two reviewers. Disagreements were resolved by consensus and, when necessary, by recourse to a third reviewer. The primary outcomes of interest were wound healing and cost. Results of data extraction and quality assessment were presented in structured tables and also as a narrative summary. In addition, where feasible, the results of individual studies were presented as forest plots. Studies were grouped according to the type of wound, debriding method and outcome measure used. RESULTS - CLINICAL EFFECTIVENESS: Seventeen trials met the inclusion criteria, all of which used the autolytic method of debridement. No studies were found that investigated sharp/surgical, biosurgical, mechanical, chemical or enzymatic debridement in the treatment of surgical wounds healing by secondary intention. No studies were found which investigated specialised wound care clinics that included the provision of care within a clinical setting (based in either primary or secondary care). The type of surgical wounds investigated by studies included in the review were those that had broken down postoperatively, perineal wounds resulting from proctolectomy or rectal excision, and those left open after pilonidal sinus excision or abscess incision, or wounds following a laparotomy. Four additional studies investigated treatment of postoperative wounds from toenail avulsions. (ABSTRACT TRUNCATED)
Topics: Clinical Trials as Topic; Cost-Benefit Analysis; Debridement; Delivery of Health Care; Humans; Postoperative Complications; Technology Assessment, Biomedical; Treatment Outcome; United Kingdom; Wound Healing
PubMed: 11399237
DOI: 10.3310/hta5140