This is the current release of the guideline.

This guideline updates a previous version: Practice parameters for treatment of fistula-in-ano. The Standards Practice Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum 1996 Dec;39(12):1361-2.

Perianal abscess and fistula-in-ano

Management
Treatment

Colon and Rectal Surgery

Advanced Practice Nurses
Nurses
Patients
Physician Assistants
Physicians

To provide uniform parameters for the treatment of perianal abscess and fistula-in-ano

Patients with perianal abscess and fistula-in-ano

Treatment of Perianal Abscess

1. Incision and drainage
2. Antibiotic use (not routinely recommended)

Treatment of Fistula-in-Ano (Simple, Complex, and Associated with Crohn's Disease)

1. Fistulotomy
2. Track debridement and fibrin glue injection
3. Endorectal advancement flap closure
4. Seton use and/or staged fistulotomy
5. No intervention (for asymptomatic Crohn's fistulas)

• Healing rates and times
• Fistula recurrence rate
• Minor and major incontinence rate
• Infection rate
• Success rate of interventions
• Side effects of treatment
• Patient satisfaction
• Proctectomy rates

Searches of Electronic Databases

Pertinent information from the published literature through December 2003 was retrieved and reviewed. Organized searches of MEDLINE and the Cochran Database of Systematic Reviews were performed. Keywords included: abscess, fistula, fistula-in-ano, anal, rectal, perianal, rectovaginal, seton, and Crohn's. Directed searches of the embedded references from primary articles also were accomplished.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence (Class)

1. Meta-analysis of multiple well-designed, controlled studies; randomized trials with low false-positive and low false-negative errors (high power)
2. At least one well-designed experimental study; randomized trials with high false-positive or high false-negative errors or both (low power)
3. Well-designed, quasi-experimental studies, such as nonrandomized, controlled, single-group, preoperative-postoperative comparison, cohort, time, or matched case-control series
4. Well-designed, nonexperimental studies, such as comparative and correlational descriptive and case studies
5. Case reports and clinical examples

Systematic Review

Not stated

Expert Consensus

Not stated

Grades of Recommendations

1. Evidence of Type I or consistent findings from multiple studies of Type II, III, or IV
2. Evidence of Type II, III, or IV and generally consistent findings
3. Evidence of Type II, III, or IV but inconsistent findings
4. Little or no systematic empirical evidence

A formal cost analysis was not performed and published cost analyses were not reviewed.

Not stated

Not applicable

The levels of evidence (classes I-V) and the grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.

Perianal Abscess

Treatment Recommendations

1. A perianal abscess should be treated in a timely fashion by incision and drainage. Level of Evidence: Class IV; Grade of Recommendation: B.
2. Antibiotics are an unnecessary addition to routine incision and drainage of uncomplicated perianal abscesses. Level of Evidence: Class II; Grade of Recommendation: A.

Fistula-in-Ano

Treatment of a Simple Fistula-in-Ano

1. Simple anal fistulas may be treated by fistulotomy. Level of Evidence: Class II; Grade of Recommendation: B.
2. Simple anal fistulas may be treated with track debridement and fibrin glue injection. Level of Evidence: Class IV; Grade of Recommendation: B.

Treatment of a Complex Fistula-in-Ano

1. Complex anal fistulas may be treated with debridement and fibrin glue injection. Level of Evidence: Class IV; Grade: B.
2. Complex anal fistulas may be treated with endorectal advancement flap closure. Level of Evidence: Class IV; Grade: B.
3. Complex fistulas may be treated by the use of a seton and/or staged fistulotomy. Level of Evidence: Class IV; Grade: B.

Treatment of Fistula-in-Ano with Crohn's Disease

1. Asymptomatic Crohn's fistulas need not be treated. Level of Evidence: Class IV; Grade: B.
2. Simple, low Crohn's fistulas may be treated by fistulotomy. Level of Evidence: Class IV; Grade: B.
3. Complex Crohn's fistulas may be well palliated with long-term draining setons. Level of Evidence: Class IV; Grade: B.
4. Complex Crohn's fistulas may be treated with advancement flap closure if the rectal mucosa is grossly normal. Level of Evidence: Class IV; Grade: B.

Definitions:

Levels of Evidence (Class)

1. Meta-analysis of multiple well-designed, controlled studies; randomized trials with low false-positive and low false-negative errors (high power)
2. At least one well-designed experimental study; randomized trials with high false-positive or high false-negative errors or both (low power)
3. Well-designed, quasi-experimental studies, such as nonrandomized, controlled, single-group, preoperative-postoperative comparison, cohort, time, or matched case-control series
4. Well-designed, nonexperimental studies, such as comparative and correlational descriptive and case studies
5. Case reports and clinical examples

Grades of Recommendations

1. Evidence of Type I or consistent findings from multiple studies of Type II, III, or IV
2. Evidence of Type II, III, or IV and generally consistent findings
3. Evidence of Type II, III, or IV but inconsistent findings
4. Little or no systematic empirical evidence

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations" field).

The guideline outlines general approaches to the treatment of patients with perianal abscess and fistula-in-ano, which may lead to more appropriate and effective treatment of these patients.

Morbidities associated with operative interventions, such as incontinence and sepsis

Active proctitis in patients with Crohn's disease is considered a contraindication for endorectal or anodermal advancement flap closure.

• These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.
• This practice parameter has been developed from sources believed to be reliable. The American Society of Colon and Rectal Surgeons makes no warranty, guaranty, or representation whatsoever as to the absolute validity or sufficiency of any parameter, and the Society assumes no responsibility for the use or misuse of the material.

An implementation strategy was not provided.

Getting Better
Living with Illness

Effectiveness

Not applicable: The guideline was not adapted from another source.

1996 (revised 2005 Jul)

American Society of Colon and Rectal Surgeons - Medical Specialty Society

Not stated

Standards Task Force of the American Society of Colon and Rectal Surgeons

Task Force Members: Mark H. Whiteford, MD; John Kilkenny III, MD; Neil Hyman, MD; W. Donald Buie, MD; Jeffrey Cohen, MD,; Charles Orsay, MD; Gary Dunn, MD; W. Brian Perry, MD; C. Neal Ellis, MD; Jan Rakinic, MD; Sharon Gregorcyk, MD; Paul Shellito, MD; Richard Nelson, MD; Joe J. Tjandra, MD; Graham Newstead, MD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Practice parameters for treatment of fistula-in-ano. The Standards Practice Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum 1996 Dec;39(12):1361-2.

None available

None available

This summary was completed by ECRI on February 15, 2000. The information was verified by the guideline developer as November 7, 2000. This NGC summary was updated by ECRI on August 9, 2005.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.