One or Two Stage Operation the Value of Seton Drainage

After the abscess is incised and drained as previously described, the fistulous tract should be drained using a seton drainage [21]. Two or three 4-0 or 5-0 non-absorbable monofilament sutures are placed from the incision of the abscess along the tract to the primary orifice (Fig. 2). They are then tied separately and loosely without tension to avoid pain and skin damage. The seton will allow drainage and promote fibrosis around the fistulous tract. In cases of Crohn's disease, setons can be used for months or years. The prevalence of abscesses in patients with perianal Crohn's disease is approximately 50% [5, 22, 23].

Abscesses in these patients may be complex and multiple requiring complementary investigations such as sonography and/or MR Imaging.

The cause of Crohn's abscesses (Fig. 3) is not completely understood. Following Park's theory, which states that an infection begins in the anal gland in the intersphincteric space and all other tracts and collections are secondary [24, 25], many investigators believe that Crohn's abscesses are no different than crypto glandular abscesses. Other investigators believe that the abscess is secondary to a cavitating ulcer that penetrates the anorectal wall, spreading sepsis to the perirectal tissue [7]. This distinction may not affect treatment. Abscesses must be drained urgently to prevent spread into adjacent tissue.

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