Abscesso anorretal

Infecções necrosante das partes moles do períneo (gangrena de Fournier) com sepse com risco de vida podem estar presentes ou se desenvolverem em pacientes com abscessos anorretais, quando houver demora no diagnóstico ou tratamento.

Este caso é mais provável em pacientes com diabetes, imunocomprometimento, debilitação crônica ou idade avançada.[3]Adinolfi MF, Voros DC, Moustoukas NM, et al. Severe systemic sepsis resulting from neglected perineal infections. South Med J. 1983 Jun;76(6):746-9. http://www.ncbi.nlm.nih.gov/pubmed/6857307?tool=bestpractice.com [11]Salvino C, Harford FJ, Dobrin PB. Necrotizing infections of the perineum. South Med J. 1993 Aug;86(8):908-11. http://www.ncbi.nlm.nih.gov/pubmed/8351552?tool=bestpractice.com

Fasciite necrosante

Entre 30% e 70% dos abscessos anorretais apresentam fístula concomitante, e cerca de 30% a 50% dos pacientes com abscesso anorretal desenvolvem uma fístula anal nos meses ou anos após a drenagem.[4]Gaertner WB, Burgess PL, Davids JS, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anorectal abscess, fistula-in-Ano, and rectovaginal fistula. Dis Colon Rectum. 2022 Aug 1;65(8):964-85. https://www.doi.org/10.1097/DCR.0000000000002473 http://www.ncbi.nlm.nih.gov/pubmed/35732009?tool=bestpractice.com [36]Hamalainen KP, Sainio AP. Incidence of fistulas after drainage of acute anorectal abscesses. Dis Colon Rectum. 1998 Nov;41(11):1357-61. http://www.ncbi.nlm.nih.gov/pubmed/9823799?tool=bestpractice.com [27]Vasilevsky CA, Gordon PH. The incidence of recurrent abscesses or fistula-in-ano following anorectal suppuration. Dis Colon Rectum. 1984 Feb;27(2):126-30. http://www.ncbi.nlm.nih.gov/pubmed/6697831?tool=bestpractice.com

Se o exame no momento da drenagem cirúrgica revelar uma fístula anal associada, embora controverso, pode-se considerar o tratamento da fístula ao mesmo tempo.[28]Tang CL, Chew SP, Seow-Choen F. Prospective randomized trial of drainage alone vs. drainage and fistulotomy for acute perianal abscesses with proven internal opening. Dis Colon Rectum. 1996 Dec;39(12):1415-7. http://www.ncbi.nlm.nih.gov/pubmed/8969668?tool=bestpractice.com [30]Cox SW, Senagore AJ, Luchtefeld MA, et al. Outcome after incision and drainage with fistulotomy for ischiorectal abscess. Am Surg. 1997 Aug;63(8):686-9. http://www.ncbi.nlm.nih.gov/pubmed/9247434?tool=bestpractice.com [31]Knoefel WT, Hosch SB, Hoyer B, et al. The initial approach to anorectal abscesses: fistulotomy is safe and reduces the chance of recurrences. Dig Surg. 2000;17(3):274-8. http://www.ncbi.nlm.nih.gov/pubmed/10867462?tool=bestpractice.com [32]Malik AI, Nelson RL, Tou S. Incision and drainage of perianal abscess with or without treatment of anal fistula. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD006827. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006827.pub2/abstract http://www.ncbi.nlm.nih.gov/pubmed/20614450?tool=bestpractice.com Se a fístula anal for superficial e envolver menos de 30% do mecanismo esfincteriano, alguns cirurgiões acreditam que a fístula anal pode ser tratada com fistulotomia.[4]Gaertner WB, Burgess PL, Davids JS, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anorectal abscess, fistula-in-Ano, and rectovaginal fistula. Dis Colon Rectum. 2022 Aug 1;65(8):964-85. https://www.doi.org/10.1097/DCR.0000000000002473 http://www.ncbi.nlm.nih.gov/pubmed/35732009?tool=bestpractice.com