Perirectal Abscess in Crohn's Disease Drainage and Outcome TIMOTHY J. PRITCHARD, M.D.,* DAVID J. SCHOETZ,JR., M.D., PATRICA L. ROBERTS, M.D., JOHN J. MURgAY, M.D., JOHN A. COLLER, M.D., MALCOLMC. VEIDENHEIMER, M.D. Pritchard TJ, Schoetz DJ Jr., Roberts PL, Murray JJ, Coller JA, Veidenheimer MC. Perirectal abscess in Crohn's disease: drain- age and outcome. Dis Colon Rectum 1990;33:933--937. The role of surgical intervention in the treatment of patients with anorectal Crohn's disease is controversial. To clarify the success of aggressive drainage and the subsequent clinical course of pa- tients with Crohn's disease and perirectal abscesses, the authors reviewed the records of 38 patients who presented with this con- dition during an eight-year period. Twenty-two male and 16 fe- male patients (median age, 32 years; range, 17 to 61 years) with clinically or pathologically confirmed Crohn's disease of the bowel underwent operation for perirectal abscesses. Thirty-two percent of patients had no previous history of anorectal Crohn's disease. Thirty simple abscesses and 8 complex horseshoe ab- scesses were treated. At operation, 53 percent of patients under- went incision and drainage whereas 26 percent received loop indwelling drains and 21 percent had mushroom catheters placed. After resolution of the index abscess, recurrent abscesses occurred in 45 percent of the patients who underwent catheter drainage and 56 percent of the patients who underwent incision and drainage. More importantly, 44 percent of the incision and drainage group and only 31 percent of the catheter drainage group required subsequent proctectomy to control perineal sep- sis. The healing time of the perineal wound was longer than six months in 83 percent of patients requiring rectal excision. We concluded that long-term catheter drainage may offer substantial benefit in the overall outcome of the treatment of patients with Crohn's disease and perirectal abscess. [Key words: Anal Crohn's disease; Perirectal abscess; Horseshoe abscess; Catheter drain- age; Anal fistula] Read at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Ontario, Canada, June 11 to 16, 1989. Address reprint requests to Dr. Schoetz: Department of Colon and Rectal Surgery, Lahey Clinic Medical Center, 41 Mall Road, Burlington, Massachusetts 01805. *Current address: Department of Surgery, University Hospitals of Cleveland, Cleveland, Ohio. From the Department of Colon and Rectal Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts PERIANAL DISEASE THAT may require either medical or surgical therapy for control of symptoms is a fre- quent complication in patients with Crohn's disease.1 Perirectal abscess may be a prominent manifestation of this pathologic condition. Controversy persists as to the proper surgical management of the abscess. Most reports on the treatment of anorectal Crohn's disease recommend a surgically conservative ap- proach consisting of incision and drainage of ab- scesses, minimal fistulotomy or sphincterotomy for treatment of anal fistulae, and dilatation of anal strictures. 2-5 In addition, the benefits of the chronic administration of metronidazole for the alleviation of symptomatic perineal Crohn's disease have been well documented. 6'7 In patients with severe perianal dis- ease refractory to either medical therapy or conser- vative surgical intervention, proctectomy offers a de- finitive option for cure because it removes the offend- ing diseased bowel that is the source of continuing perineal sepsis. Historically, healing of perineal wounds after conservative procedures and proctec- tomy has been compromised because of the combined effects of malnutrition, the chronic administration of corticosteroids, and underlying sepsis. The purpose of our study was to determine the efficacy and outcome of simple incision and drainage and of indwelling catheter drainage in the treatment of perirectal abscess in patients with Crohn's disease. 933