Pelvic abscess after colon and rectal surgery--what is optimal management?

The aim of this study was to compare treatment outcomes in the management of pelvic abscess (PA) after rectal surgery.

Over a 12-year period all PAs occurring in the patients undergoing colorectal resection were retrospectively reviewed. The APACHE II Score was used to stratify illness.

Postoperative PA developed in 56 patients after cancer (32 percent), ulcerative colitis (26 percent), diverticular disease (24 percent), and Crohn's colitis (18 percent)/surgery. Overall, 24 (43 percent) of PAs were after operations for inflammatory bowel disease and 43 (77 percent) of PAs were after intrapelvic intestinal anastomoses. PAs were treated by 1) antibiotics alone (11/56), 2) percutaneous computerized tomography-guided catheter drainage (13/56), 3) transperineal drainage (15/56), or 4) laparotomy (17/56). Recurrent PAs developed in 11/56 (19 percent) after initial treatment, of which 7 required additional surgery. These recurrences were evenly distributed between treatment groups. There were three deaths as a result of PA, two after laparotomy and one after percutaneous drainage. Long-term sequela in patients with intestinal anastomosis included loss of intestinal continuity (10/43) and anastomotic stenosis (7/43). There was no difference in APACHE II Score among the four treatment groups. The mortality rate was 75 percent among patients whose APACHE II Scores were greater than 15. The development of a PA after colon and rectal surgery was associated with a 5 percent mortality and 41 percent functional morbidity (23 percent permanent stoma and 18 percent symptomatic stricture rate).

Using clinical judgment, if PA is amenable to computerized tomography-guided percutaneous or transperineal drainage, one of these techniques should be attempted initially in the hemodynamically stable nonseptic patient. Long-term functional disability is common after PA in rectosigmoid surgery in patients who undergo pelvic/intestinal anastomosis.