Supralevator abscess – clinic, diagnosis and treatment

INTRODUCTION : The supralevator abscess, though uncommon, is a significant issue in the emergent colorectal surgery, due to its atypical symptoms, surgical tactics and frequent postoperative failure. AIM:  The aim of this article is to analyze the frequency, the diagnostic difficulties and the clinical features by improving the results of their treatment through the timely diagnosis and rational surgical tactics. MATERIALS AND METHODS : For a period of 15 years, from 2004 to 2018, a retrospective analysis of 845 urgently admitted patients, with an acute anorectal abscess (ARA) was done. Depending on the localization, we established four types of ARA: perianal – 392 patients (46.39%), ischiorectal – 287 patients (33.96%), intersphincteric – 93 patients (11.01%), and  supralevator – 73 patients (8.64%). Superficial localization was determined in 450 patients (53,25%) and deep - in 395 (46.75%). Males were 53 (72.60%) and females were 20 (27.40%), with a ratio of 2.65:1. The age of the patients varied between 17 to 85 years old, with an average age of 51.27 ± 8.43 years. The following operations were performed: single surgery in 39 patients (53.42%) - two incisions, revision, necrectomy, lavage and drainage №2, and in 34 reoperated patients (46.58%) – reincisions, revision, necrectomy and redrainage.  RESULTS : In all of the cases the early signs of a supralevator abscess were atypical, therefore timely diagnosis was exceptionally rare. After the formation of the purulent collection, an inflammatory intoxication syndrome with manifestations of sepsis was determined. The main diagnostic methods in patients with supralevator abscess were digital rectal examination, rectoscopy, anoscopy, transrectal ultrasound, CT and MRI of the pelvis. During the operation in 25 patients (34.25%) with supralevator abscess, a rubber seton ligature was placed through the internal opening for gradual tightening of the sphincter. There were no patients with a lethal outcome. CONCLUSION: The variety and atypical presentation of the supralevator abscess makes the diagnosis difficult, which may lead to delays of hospital admission and operative treatment. The timely and adequate removal of the purulent necrotic structures requires total necrectomy until full mechanical eradication, followed by daily control and proper follow-up of the postoperative period.