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## Complete Summary

#### GUIDELINE TITLE

Practice parameters for the treatment of perianal abscess and
fistula-in-ano (revised).

#### BIBLIOGRAPHIC SOURCE(S)

Whiteford MH, Kilkenny J 3rd, Hyman N, Buie WD, Cohen J, Orsay C, Dunn
G, Perry WB, Ellis CN, Rakinic J, Gregorcyk S, Shellito P, Nelson R,
Tjandra JJ, Newstead G. Practice parameters for the treatment of
perianal abscess and fistula-in-ano (revised). Dis Colon Rectum 2005
Jul;48(7):1337-42. \[63 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15933794)

#### GUIDELINE STATUS

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.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Perianal abscess and fistula-in-ano

#### GUIDELINE CATEGORY

Management\
Treatment

#### CLINICAL SPECIALTY

Colon and Rectal Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Patients\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

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

#### TARGET POPULATION

Patients with perianal abscess and fistula-in-ano

#### INTERVENTIONS AND PRACTICES CONSIDERED

**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)

#### MAJOR OUTCOMES CONSIDERED

-   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

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

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.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence (Class)**

I.  Meta-analysis of multiple well-designed, controlled studies;
    randomized trials with low false-positive and low false-negative
    errors (high power)

II. At least one well-designed experimental study; randomized trials
    with high false-positive or high false-negative errors or both (low
    power)

III. Well-designed, quasi-experimental studies, such as nonrandomized,
     controlled, single-group, preoperative-postoperative comparison,
     cohort, time, or matched case-control series

IV. Well-designed, nonexperimental studies, such as comparative and
    correlational descriptive and case studies

V.  Case reports and clinical examples

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grades of Recommendations**

A.  Evidence of Type I or consistent findings from multiple studies of
    Type II, III, or IV

B.  Evidence of Type II, III, or IV and generally consistent findings

C.  Evidence of Type II, III, or IV but inconsistent findings

D.  Little or no systematic empirical evidence

#### COST ANALYSIS

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

#### METHOD OF GUIDELINE VALIDATION

Not stated

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not applicable

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

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]{.underline}**

**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]{.underline}**

**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]{.underline}**:

**Levels of Evidence (Class)**

I.  Meta-analysis of multiple well-designed, controlled studies;
    randomized trials with low false-positive and low false-negative
    errors (high power)

II. At least one well-designed experimental study; randomized trials
    with high false-positive or high false-negative errors or both (low
    power)

III. Well-designed, quasi-experimental studies, such as nonrandomized,
     controlled, single-group, preoperative-postoperative comparison,
     cohort, time, or matched case-control series

IV. Well-designed, nonexperimental studies, such as comparative and
    correlational descriptive and case studies

V.  Case reports and clinical examples

**Grades of Recommendations**

A.  Evidence of Type I or consistent findings from multiple studies of
    Type II, III, or IV

B.  Evidence of Type II, III, or IV and generally consistent findings

C.  Evidence of Type II, III, or IV but inconsistent findings

D.  Little or no systematic empirical evidence

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

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

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

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.

#### POTENTIAL HARMS

Morbidities associated with operative interventions, such as
incontinence and sepsis

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

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

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   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.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Whiteford MH, Kilkenny J 3rd, Hyman N, Buie WD, Cohen J, Orsay C, Dunn
G, Perry WB, Ellis CN, Rakinic J, Gregorcyk S, Shellito P, Nelson R,
Tjandra JJ, Newstead G. Practice parameters for the treatment of
perianal abscess and fistula-in-ano (revised). Dis Colon Rectum 2005
Jul;48(7):1337-42. \[63 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15933794)

#### ADAPTATION

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

#### DATE RELEASED

1996 (revised 2005 Jul)

#### GUIDELINE DEVELOPER(S)

American Society of Colon and Rectal Surgeons - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

Not stated

#### GUIDELINE COMMITTEE

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

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*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

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

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.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Society of Colon and Rectal Surgeons (ASCRS) Web
site](http://www.fascrs.org/files/pp_0705.pdf).

Print copies: Available from the ASCRS, 85 W. Algonquin Road, Suite 550,
Arlington Heights, Illinois 60005.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

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.

#### COPYRIGHT STATEMENT

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

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008