Anorectal Emergencies: Perianal Abscesses and Fistulas—A Modern Surgical Approach to Treatment

Abstract

Introduction: Perianal abscess and anal fistulas are two phases of a cryptoglandular disease spectrum that frequently present as surgical emergencies and carry substantial risks of recurrence, persistent sepsis, and continence impairment. Despite a long surgical tradition, practice is shifting as contemporary randomized trials and guidelines refine indications for antibiotics, wound packing, imaging, and sphincter-sparing repair.

Aim: The aim of this article is to provide a narrative synthesis of current evidence informing emergency management of perianal abscess and the operative treatment of cryptoglandular and Crohn’s-related fistulas, with attention to imaging, perioperative decision-making, technique selection, and evolving therapies.

Background: Early goals in abscess care are source control and pain relief. Contemporary guidelines discourage routine postoperative packing and routine antibiotics after uncomplicated incision and drainage (I&D), reserving antibiotics for systemic illness, extensive cellulitis, or immunosuppression. High-quality evidence (PPAC2) shows that non-packing reduces pain without increasing failure, while the role of antibiotic prophylaxis in preventing subsequent fistula remains unsettled pending ongoing trials. Magnetic resonance imaging (MRI) (and 3D-EAUS where expertise exists) are pivotal for mapping complex tracts, guiding timing and choice of sphincter-preserving operations. For simple, low cryptoglandular fistulas, fistulotomy remains standard with careful continence risk stratification. For high or complex fistulas, options include endorectal advancement flap and LIFT, which have broadly comparable success but lower de-novo incontinence after LIFT. Energy/video-assisted approaches (FiLaC, VAAFT) show promising continence preservation with variable healing rates; selection and meticulous technique are critical. In perianal Crohn’s disease, urgent drainage with a seton control of sepsis should be coordinated with biologic therapy. Recent regulatory actions have withdrawn darvadstrocel from the EU market after confirmatory trial failure, narrowing regenerative options.

Conclusions: Management should prioritize individualized risk, disciplined imaging, and stepwise, sphincter-preserving strategy. Key practice changes include abandoning routine packing, being judicious with antibiotics, using MRI for complex disease, and aligning high fistula surgery with continence preservation and, in Crohn’s disease, with optimized medical therapy.