WSES-AAST guidelines on anorectal emergencies released
Italy: The World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) has released a new guideline on the management of anorectal emergencies.
Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome.
The paper, published in the World Journal of Emergency Surgery, aims to improve the knowledge and awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.
The guideline was developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the WSES and AAST to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application.
Anorectal abscess
- In patients with suspected anorectal abscess, we suggest to collect a focused medical history and to perform a complete physical examination, including a digital rectal examination.
- In patients with suspected anorectal abscess, we suggest to check serum glucose, hemoglobin a1c, and urine ketones in order to identify an undetected diabetes mellitus.
- In patients with suspected anorectal abscess and signs of systemic infection or sepsis, we suggest to request complete blood count, serum creatinine, and inflammatory markers (e.g., C-reactive protein, procalcitonin, and lactates), to assess the status of the patient.
- In patients with suspected anorectal abscess, we suggest the use of imaging investigations in case of atypical presentation and in case of suspicion of occult supralevator abscesses, complex anal fistula, or perianal Crohn's disease. Suggested techniques are MRI, CT scan, or endosonography according to the specific clinical scenario and the available skills and resources.
- In patients with anorectal abscess, we recommend a surgical approach with incision and drainage.
- In patients with anorectal abscess, we suggest to base the timing of surgery on the presence and severity of sepsis.
- In fit, immunocompetent patients with a small perianal abscess and without systemic signs of sepsis, we suggest considering an outpatient management.
- No recommendation can be made regarding the use of packing after drainage of an anorectal abscess, based on the available literature.
- In patients with anorectal abscess and an obvious fistula, we suggest to perform a fistulotomy at the time of abscess drainage only in cases of low fistula not involving sphincter muscle (i.e., subcutaneous fistula).
- In patients with anorectal abscess and an obvious fistula involving any sphincter muscle, we suggest to place a loose draining seton.
- In patients with anorectal abscess and no obvious fistula, we suggest against probing to search for a possible fistula, to avoid iatrogenic complications.
- In patients with drained anorectal abscess, we suggest antibiotic administration in the presence of sepsis and/or surrounding soft tissue infection or in case of disturbances of the immune response.
- In patients with anorectal abscess, we suggest sampling of drained pus in high-risk patients and/or in the presence of risk factors for multidrug-resistant organism infection
Perineal necrotizing fasciitis
- In patients with suspected Fournier's gangrene, we suggest to collect a focused medical history and a complete physical examination, including a digital rectal examination.
- In patients with suspected Fournier's gangrene and signs of systemic infection or sepsis, we suggest to request complete blood count and the dosage of serum creatinine and electrolytes, inflammatory markers (e.g., C-reactive protein, procalcitonin), and blood gas analysis, to assess the status of the patient.
- We also recommend to check serum glucose, hemoglobin a1c and urine ketones in order to investigate an undetected diabetes mellitus.
- In patients with suspected Fournier's gangrene, we suggest to use Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score for an early diagnosis and Fournier's Gangrene Severity Index (FGSI) for prognosis and risk stratification.
- In stable patients with suspected Fournier's gangrene, we suggest to consider performing a CT scan.
- In patients with Fournier's gangrene, we recommend that imaging should not delay surgical intervention.
- In patients with Fournier's gangrene and hemodynamic instability persisting after proper resuscitation, we suggest against CT imaging.
- In patients with Fournier's gangrene, we recommend surgical intervention as soon as possible.
- In patients with Fournier's gangrene we suggest planning repeat surgical revisions (exploration and debridement) according to patient conditions.
- In patients with Fournier's gangrene, we suggest seriated surgical revisions until the patient is free of necrotic tissue.
- In patients with Fournier's gangrene, we suggest to remove all the necrotic tissue.
- In patients with Fournier's gangrene, we suggest a multidisciplinary and tailored approach based upon the extent of perineal involvement, the degree of fecal contamination, and the possible presence of sphincter or urethral damage.
- In patients with Fournier's gangrene, we suggest to perform orchiectomy or other genital surgery only if strictly necessary and possibly based on a urologic consultation.
- In patients with Fournier's gangrene, we suggest planning the surgical management of early and delayed surgical sequelae with a multidisciplinary and skilled team.
- In patients with Fournier's gangrene, we recommend starting an empiric antimicrobial therapy as soon as the diagnosis is suspected.
- In patients with Fournier's gangrene, we recommend that empiric antimicrobial therapy should include cover for gram-positive, gram-negative, aerobic and anaerobic bacteria, and an anti-MRSA agent.
- In patients with Fournier's gangrene, we recommend to obtain microbiological samples at the index operation.
- In patients with Fournier's gangrene, we recommend to base antimicrobial de-escalation on clinical improvement, cultured pathogens, and results of rapid diagnostic tests where available.
Source : World Journal of Emergency Surgery
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