The nonoperative management of fistula-in-ano

Presented at the 1999 Annual Meeting of the Section on Surgery of the American Academy of Pediatrics, Washington, DC, October 8-10, 1999.
https://doi.org/10.1053/jpsu.2000.6931Get rights and content

Abstract

Background/Purpose: Fistulotomy is the accepted treatment for infants with perianal fistula. Although recurrence rates range from 0% to 68%. Based on the experience of a senior colleague who noted that babies suffering from perianal fistula follow a self-limited course the authors decided to determine if this observation was accurate. Methods: A conservative approach to perianal abscess and fistula was used prospectively in 18 male infants. Abscesses were to be drained only if the baby was very uncomfortable or febrile. Once a fistula developed the authors continued observation until the fistula healed. Data are expressed as mean ± SD. Mean follow-up period was 37 months. Results: Mean age at onset of symptoms was 4 ± 3 months. Fistulas developed in 14 patients (77%). All fistulas healed without operation. Four patients had abscesses drained for discomfort (n = 3) or fever (n = 1). No patient required antibiotics. Mean duration of symptoms was 6 ± 4 months. Four patients in whom fistulas did not form healed after incision (n = 3) or spontaneous drainage (n = 1). All patients currently are asymptomatic. Conclusions: In healthy neonates, perianal abscess and fistula are self-limited conditions rarely requiring surgical drainage and not requiring antibiotics. The conservative management of perianal abscess and fistula in healthy infants appears to be safe and effective. J Pediatr Surg 35:938-939. Copyright © 2000 by W.B. Saunders Company.

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Materials and methods

A prospective conservative approach to perianal abscess and fistula was undertaken in 18 infants presenting between 1990 and 1999. Abscesses were incised and drained and antibiotics administered only if the baby was very uncomfortable or had septic manifestations. Once a fistula was established we continued expectant management with follow-up at 3-month intervals until the fistula disappeared. We explained to parents that fistulotomy could be performed at any time if the fistula provoked pain

Results

All patients in this series were boys. The mean age at onset of symptoms was 4.2 ± 2.8 months (range, 0.3 to 9.7 months). Four patients had abscesses incised and drained under local anesthesia for discomfort (n = 3) or fever (n = 1). The remaining 14 patients' abscesses drained spontaneously. Two patients received courses of oral antibiotics before our surgical evaluation after which no patient received antibiotic therapy.

Fistulas developed in 14 patients (77%). All patients had complete

Discussion

Perianal abscesses and fistulas in neonates are different conditions than those found in older children. The male preponderance of these conditions as seen in the current series, has been well described.4 Older children presenting with perianal abscesses or fistulas tend to have a higher incidence of underlying conditions such as inflammatory bowel disease or leukemia.5, 6 Fistula-in-ano in an otherwise healthy neonate is suspected to originate as anal cryptitis, which progresses to form a

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Address reprint requests to Alberto Peña, MD, Chief, Division of Pediatric Surgery, CH-158, Schneider Children's Hospital, 269-01 76th Ave, New Hyde Park, NY 11040.

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