Peri-Anal Sepsis in the Neutropenic Patient – Strategy Revisited

Mortality rates for neutropenic patients with peri-anal sepsis are high, but there is no consensus in the literature as to the optimal management strategy. At Leicester Royal Infirmary, UK, we have adopted a multidisciplinary approach as standard, with broad-spectrum antibiotics, peri-anal examination with debridement if necessary, and routine defunctioning colostomy. Eleven patients were treated according to this protocol between January 2001 and December 2015, with 9/11 full recovery from the sepsis and the procedure, and 5 subsequently having colostomy reversal. In an area of relatively scant evidence, we conclude that these patients should not be denied a surgical procedure. Patients are admitted under the care of a haematologist, and the management strategy begins with isolation and fluid resuscitation of the individual, followed by blood cultures and the swift commencement of broad-spectrum antibiotics. Early consultation with a surgeon takes place, in liaison with a colorectal nurse-specialist who counsels the patient regarding stoma formation, with marking of an appropriate abdominal site. Formal peri-anal examination is performed under general anaesthetic with the patient in the lithotomy position, and drainage with debridement is clinically indicated in the presence of in duration or swelling which may be in the presence of florid erythema. Temporary faecal diversion is universally performed with a loop sigmoid colostomy, with a view to reversal once the sepsis has resolved. The full course of antibiotics is completed.