Reviewing perianal abscess management and recurrence: lessons from a trainee perspective

Background: Perianal abscesses are a common surgical emergency. Due to their perceived ease, drainage is often delegated to junior trainees with varying levels of experience. The purpose of this study is to evaluate the current trend in perianal abscesses management at our institution, and identify factors that predict subsequent fistula formation or abscess recurrence.

Methods: All acute patients admitted to a major teaching hospital who required surgical drainage of a perianal abscess were analysed over a two-year period from January 2019 to December 2020. Patient demographics, clinical and laboratory findings were retrospectively reviewed. Proceduralist experience, operative management strategy and recurrence rates (fistula or abscess) were analysed.

Results: The mean age of patients was 43 years old, and 73% were male. Trainees performed 96% of the procedures. Re-presentation with a fistula or abscess recurrence requiring further surgery was 31%. Comorbidities of IBD, diabetes, or malignancy were present in one-third of patients and significantly increased the risk of recurrence (P = 0.01). Searching for a fistula tract was performed in 41% of cases but did not reduce recurrence (P = 0.9). Seton insertion occurred in 10%, and fistulotomy in 2%.

Conclusion: Perianal abscess drainage at our institution is almost exclusively performed by trainees, the majority of which occurs after-hours. Patients who present with a fever, inflammatory bowel disease, diabetes mellitus or malignancy are at an increased risk of recurrent abscess or a subsequent fistula after drainage, and input from an experienced surgeon may be of value when considering seton insertion or fistulotomy.