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Techniques in Coloproctology

, Volume 18, Issue 4, pp 327–333 | Cite as

Management of acute perianal sepsis in neutropenic patients with hematological malignancy

  • B. Baker
  • M. Al-Salman
  • F. Daoud
Review

Abstract

In neutropenic patients with acute perianal sepsis in the setting of hematological malignancy, the classical clinical features of abscess formation are lacking. Additionally, the role of surgical intervention is not well established. In this review, we discuss the challenges and controversy regarding diagnosis and optimal management when clear surgical guidelines are absent. In the literature, there is great diversity in the surgical approach to these patients, which leads to a high percentage of diagnostic errors, risks of complications, and unnecessary interventions. We review the literature and assess whether surgical intervention produces better outcomes than a non-surgical approach. Studies published on perianal sepsis in neutropenic cancer patients were identified by searching PubMed using the following key words: “perianal sepsis/abscesses, anorectal sepsis/abscess, neutropenia, hematological malignancy, cancer”. No randomized or prospective studies on the management of acute perianal sepsis in hematological malignancies were found. The largest retrospective study and most comprehensive clinical data demonstrated that 42 % of patients were treated successfully without surgical intervention and without morbidity or mortality related to treatment chosen. Small retrospective studies advocated surgical intervention, while the majority of successes were in a non-operative treatment. It is difficult to formulate a conclusion given the small retrospective series on management of neutropenic patients with hematological malignancies. While there is no evidence mandating a routine surgical approach in this category of patients, non-surgical management including careful follow-up to determine whether the patient’s condition is deteriorating or treatment has failed is an acceptable approach in selected patients without pathognomonic features of abscess. Comprehensive and well-designed prospective studies are needed to firmly establish the guidelines of treatment protocols.

Keywords

Perianal sepsis/abscess Neutropenia Hematological malignancy 

Notes

Acknowledgments

The authors thank Miss Bayan Baker, research assistant at Sarah Lawrence College Chemistry Laboratory for the final editing of the manuscript.

Conflict of interest

None.

References

  1. 1.
    Büyükaşik Y, Ozcebe OI, Sayinalp N et al (1998) Perianal infections in patients with leukemia: importance of the course of neutrophil count. Dis Colon Rectum 41:81–85PubMedCrossRefGoogle Scholar
  2. 2.
    Barnes SG, Sattler SF, Ballard JO (1984) Perirectal infections in acute leukemia. Improved survival after incision and debridement. Ann Intern Med 100:515–518PubMedCrossRefGoogle Scholar
  3. 3.
    Rolston KV, Bodey BG (1993) Diagnosis and management of perianal and perirectal infection in the granulocytopenic patient. Curr Clin Top Infect Dis 13:164–171PubMedGoogle Scholar
  4. 4.
    Slater DN (1984) Perianal abscess: “Have I excluded leukaemia”? Br Med J (Clin Res Ed) 289:1682CrossRefGoogle Scholar
  5. 5.
    Papaconstantinou I, Yiallourou AI, Dafnios N, Grapsa I, Polymeneas G, Voros D (2011) Successful treatment of a severe case of Fournier’s gangrene complicating a perianal abscess. Case Rep Med 2011:702429PubMedCentralPubMedGoogle Scholar
  6. 6.
    Badgwell BD, Chang GJ, Rodriguez-Bigas MA et al (2009) Management and outcomes of anorectal infection in the cancer patient. Ann Surg Oncol 16:2752–2758PubMedCrossRefGoogle Scholar
  7. 7.
    Schimpff SC, Wiernik PH, Block JB (1972) Rectal abscesses in cancer patients. Lancet 2:844–847PubMedCrossRefGoogle Scholar
  8. 8.
    Sickles EA, Greene WH, Wiernik PH (1975) Clinical presentation of infection in granulocytopenic patients. Arch Intern Med 135:715–719PubMedCrossRefGoogle Scholar
  9. 9.
    Vanhueverzwyn R, Delannoy A, Michaux JL, Dive C (1980) Anal lesions in hematologic diseases. Dis Colon Rectum 23:310–312PubMedCrossRefGoogle Scholar
  10. 10.
    Cohen JS, Paz IB, O’Donnell MR, Ellenhorn JD (1996) Treatment of perianal infection following bone marrow transplantation. Dis Colon Rectum 39:981–985PubMedCrossRefGoogle Scholar
  11. 11.
    Lehrnbecher T, Marshall D, Gao C, Chanock SJ (2002) A second look at anorectal infections in cancer patients in a large cancer institute: the success of early intervention with antibiotics and surgery. Infection 30:272–276PubMedCrossRefGoogle Scholar
  12. 12.
    Shaked AA, Shinar E, Freund H (1986) Managing the granulocytopenic patient with acute perianal inflammatory disease. Am J Surg 152:510–512PubMedCrossRefGoogle Scholar
  13. 13.
    Corfitsen MT, Hansen CP, Christensen TH, Kaae HH (1992) Anorectal abscesses in immunosuppressed patients. Eur J Surg 158:51–53PubMedGoogle Scholar
  14. 14.
    Musa MB, Katakkar SB, Khaliq A (1975) Anorectal and perianal complications of hematologic malignant neoplasms. Can J Surg 18:579–583PubMedGoogle Scholar
  15. 15.
    Merrill JM, Brereton HD, Kent CH, Johnson RE (1976) Anorectal disease in patients with non-haematological malignancy. Lancet 1:1105–1107PubMedCrossRefGoogle Scholar
  16. 16.
    North JH Jr, Weber TK, Rodriguez-Bigas MA, Meropol NJ, Petrelli NJ (1996) The management of infectious and noninfectious anorectal complications in patients with leukemia. J Am Coll Surg 183:322–328PubMedGoogle Scholar
  17. 17.
    Boddie AW Jr, Bines SD (1986) Management of acute rectal problems in leukemic patients. J Surg Oncol 33:53–56PubMedCrossRefGoogle Scholar
  18. 18.
    Ramanujam PS, Prasad ML, Abcarian H, Tan AB (1984) Perianal abscesses and fistulas. A study of 1,023 patients. Dis Colon Rectum 27:593–597PubMedCrossRefGoogle Scholar
  19. 19.
    Cox SW, Senagore AJ, Luchtefeld MA, Mazier WP (1997) Outcome after incision and drainage with fistulotomy for ischiorectal abscess. Am Surg 63:686–689PubMedGoogle Scholar
  20. 20.
    Onaca N, Hirshberg A, Adar R (2001) Early reoperation for perirectal abscess: a preventable complication. Dis Colon Rectum 44:1469–1473PubMedCrossRefGoogle Scholar
  21. 21.
    Held D, Khubchandani I, Sheets J, Stasik J, Rosen L, Riether R (1986) Management of anorectal horseshoe abscess and fistula. Dis Colon Rectum 29:793–797PubMedCrossRefGoogle Scholar
  22. 22.
    Rosen SA, Colguhoun P, Efron J et al (2006) Horseshoe abscesses and fistulas: how are we doing? Surg Innov 13:17–21PubMedCrossRefGoogle Scholar
  23. 23.
    Stremitzer S, Strobl S, Kure V et al (2011) Treatment of perianal sepsis and long-term outcome of recurrence and continence. Colorectal Dis 13:703–707PubMedCrossRefGoogle Scholar
  24. 24.
    Grewal H, Guillem JG, Quan SH, Enker WE, Cohen AM (1994) Anorectal disease in neutropenic leukemic patients. Operative vs. nonoperative management. Dis Colon Rectum 37:1095–1099PubMedCrossRefGoogle Scholar
  25. 25.
    Steele SR, Kumar R, Feingold DL, Rafferty JL, Buie WD, Standards Practice Task Force of the American Society of Colon and Rectal Surgeons (2011) Practice parameters for the management of perianal abscess and fistula-in-ano. Dis Colon Rectum 54:1465–1474PubMedCrossRefGoogle Scholar
  26. 26.
    Cameron JL (2004) Current surgical therapy, 8th ed. Mosby, PhiladelphiaGoogle Scholar
  27. 27.
    Guillaumin E, Jeffrey RJ, Shea WJ, Asling CW, Goldberg HI (1986) Perirectal inflammatory disease: CT findings. Radiology 161:153–157PubMedGoogle Scholar
  28. 28.
    Rajan DK, Scharer KA (1998) Radiology of Fournier’s gangrene. AJR Am J Roentgenol 170:163–168PubMedCrossRefGoogle Scholar
  29. 29.
    Guy R (2003) Magnetic resonance imaging for primary fistula in ano. Br J Surg 90:877–881CrossRefGoogle Scholar
  30. 30.
    Joyce M, Veniero JC, Kiran RP (2008) Magnetic resonance imaging in the management of anal fistula and anorectal sepsis. Clin Colon Rectal Surg 21:213–219PubMedCentralPubMedCrossRefGoogle Scholar
  31. 31.
    Haggett PJ, Moore NR, Shearman JD, Travis SP, Jewell DP, Mortensen NJ (1995) Pelvic and perineal complications of Crohn’s disease: assessment using magnetic resonance imaging. Gut 36:407–410PubMedCentralPubMedCrossRefGoogle Scholar
  32. 32.
    Yildirim N, Gökalp G, Öztürk E et al (2012) Ideal combination of MRI sequences for perianal fistula classification and the evaluation of additional findings for readers with varying levels of experience. Diagn Interv Radiol 18:11–19PubMedGoogle Scholar
  33. 33.
    Hebjørn M, Olsen O, Haakansson T, Andersen B (1987) A randomized trial of fistulotomy in perianal abscess. Scand J Gastroenterol 22:174–176PubMedCrossRefGoogle Scholar
  34. 34.
    Carlson GW, Ferguson CM, Amerson JR (1988) Perianal infections in acute leukemia. Second place winner: conrad Jobst Award. Am Surg 54:693–695PubMedGoogle Scholar
  35. 35.
    Glenn J, Cotton D, Wesley R, Pizzo P (1988) Anorectal infections in patients with malignant diseases. Rev Infect Dis 10:42–52PubMedCrossRefGoogle Scholar
  36. 36.
    Sehdev MK, Dowiling MD Jr, Seal SH, Stearns MW Jr (1973) Perianal and anorectal complications in leukemia. Cancer 31:149–152PubMedCrossRefGoogle Scholar
  37. 37.
    Villar HV, Warneke JA, Peck MD, Durie B, Bjelland JC, Hunter TB (1987) Role of surgical treatment in the management of complications of the gastrointestinal tract in patients with leukemia. Surg Gynecol Obstet 165:217–222PubMedGoogle Scholar
  38. 38.
    Pizzo PA (1993) Management of fever in patients with cancer and treatment-induced neutropenia. N Engl J Med 328:1323–1332PubMedCrossRefGoogle Scholar
  39. 39.
    Chirletti P, Beverati M, Apice N et al (1988) Prophylaxis and treatment of inflammatory anorectal complications in leukemia. Ital J Surg Sci 18:45–48PubMedGoogle Scholar
  40. 40.
    Boddie AW Jr, Bines SD (1986) Management of acute rectal problems in leukemic patients. J Surg Oncol 33:53–56PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2013

Authors and Affiliations

  1. 1.Surgical Oncology DepartmentKing Hussein Cancer CenterAmmanJordan

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