The Optimal Primary Treatment for Pediatric Perianal Abscess and Anal Fistula: A Systemic Review and Meta-Analysis

BackgroundPerianal abscesses and anal fistulas are common. The principle of intention-to-treat has not been considered in previous systemic reviews. Thus, the comparison between primary and post-recurrence management was confused, and the recommendation of primary treatment is obscure. The current study aims to identify the optimal initial treatment for pediatric patients.MethodsUsing PRISMA guidelines, studies were identified from MEDLINE, EMBASE, PubMed, Cochrane Library, and Google Scholar without any language or study design restriction. The inclusion criteria include original articles or articles with original data, studies of management for a perianal abscess with or without anal fistula, and patient age of <18 years. Patients with local malignancy, Crohn's disease, or other underlying predisposing conditions were excluded. Studies without analyzing recurrence, case series of <5, and irrelevant articles were excluded in the screening stage. Of the 124 screened articles, 14 articles had no full texts or detailed information. Articles written in a language other than English or Mandarin were translated by Google Translation first and confirmed with native speakers. After the eligibility process, studies that compared identified primary managements were then included in the qualitative synthesis.ResultsThirty-one studies involving 2507 pediatric patients met the inclusion criteria. The study design consisted of two prospective case series of 47 patients and retrospective cohort studies. No randomized control trials were identified. Meta-analyses for recurrence after initial management were performed with a random-effects model. Conservative treatment and drainage revealed no difference (Odds ratio [OR], 1.222; 95% Confidential interval [CI]: 0.615–2.427, p = 0.567). Conservative management had a higher risk of recurrence than surgery without statistical significance (OR 0.278, 95% CI: 0.109–0.707, p = 0.007). Compared with incision/drainage, surgery can prevent recurrence remarkably (OR 4.360, 95% CI: 1.761–10.792, p = 0.001). Subgroup analysis of different approaches within conservative treatment and operation was not performed for lacking information.ConclusionStrong recommendations cannot be made due to the lack of prospective or randomized controlled studies. However, the current study based on real primary management supports initial surgical intervention for pediatric patients with perianal abscesses and anal fistula to prevent recurrence.Level of evidenceType of study: Systemic review; Evidence level: Level II.     

超声引导下经皮经肝胆囊穿刺后继发性脓肿发生的危险因素分析

目的 探讨超声引导下经皮经肝胆囊穿刺置管引流术(Percutaneous Transhepatic Gallbladder Drainage,PTGD)术后发生继发性脓肿(Secondary abscess,SA)的发生率及其危险因素。方法 回顾性分析南京医科大学附属无锡人民医院2010年1月至2017年12月间410例经超声引导下PTGD患者的临床资料,采用单因素和多因素Logistic回归分析相关危险因素。结果 12例(2.93%,12/410)患者PTGD术后出现SA,再次针对SA穿刺引流的成功率100%。对良性疾病梗阻、基础疾病、胆囊大小、腹水、凝血功能、血小板、糖化血红蛋白(HbA_1C)、短期内引流管脱落/自行拔出等混杂因素进行校正后,Logistic回归分析表明短期内引流管脱落/自行拔出(OR=6.64,95%Cl：3.34～13.81,P=0.03)和HbA_1C＞9.0%(OR=3.38,95%Cl：1.22～7.95,P=0.04)是引起术后SA的独立危险因素。结论 SA是超声引导下PTGD术后罕见的并发症,再次穿刺引流是治疗SA有效和安全的方法。临床可通过加强对穿刺引流管的保护和应用降血糖药物,降低PTGD术后SA的发生。     

Bypass Surgery or Stenting for Left Main Coronary Artery Disease in Patients With Diabetes

Background

The randomized EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial reported a similar rate of the 3-year composite primary endpoint of death, myocardial infarction (MI), or stroke in patients with left main coronary artery disease (LMCAD) and site-assessed low or intermediate SYNTAX scores treated with percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Whether these results are consistent in high-risk patients with diabetes, who have fared relatively better with CABG in most prior trials, is unknown.

Diabetes Mellitus and Periapical Abscess: A Cross-sectional Study

IntroductionDental morbidities associated with diabetes mellitus (DM) include an increased prevalence of periodontal diseases (PDs). However, the occurrence of periapical infections in DM has not been sufficiently documented in the literature. The purpose of this study was to investigate the occurrence of periapical abscesses (PAs) in type 1 DM (T1DM) patients, type 2 DM (T2DM) patients, and nondiabetics in a hospital-based population.MethodsWe conducted a cross-sectional study by accessing the University of Florida Health Integrated Data Repository, and diagnoses of T1DM, T2DM, and PA were obtained from queries using the International Statistical Classification of Diseases, 10th Revision. The following parameters were recorded: age, sex, and race. A logistic regression model for aggregated data was used to assess the association between the occurrence of PA and the diabetic groups (T1DM, T2DM, and nondiabetic groups) after adjusting for PDs and cardiovascular disease (CVD).ResultsAmong 867,526 patients, we found 5260 (0.6%) with T1DM and 52,493 (6.1%) with T2DM. The prevalence of PAs in the total hospital population was 4923 (0.6%), 102 patients (1%) with T1DM and 766 (6%) with T2DM with statistically significant differences. In subjects without PDs, diabetic patients are almost 3 times likely to have PAs compared with nondiabetic subjects. Among subjects with PDs, the association is weaker (odds ratio = 1.35) but still significant at a level of 0.05. In subjects without CVD, DM subjects are greater than 3 times more likely to have PA, whereas among subjects with CVD, subjects with DM are 1.5 times more likely to have PA.ConclusionsA higher prevalence of PAs was reported in diabetic patients compared with the other hospital population. Comprehensive dental treatment should be administered to diabetic patients to maximize glycemic control.     

The usefulness of abscess tonsillectomy followed by intraoral drainage for parapharyngeal abscess concomitant with peritonsillar abscess in the elderly

Parapharyngeal abscess (PPA) may cause life-threatening complications and peritonsillar abscess (PTA) and tonsillitis frequently precede PPA. The optimal management of PPA caused by PTA has been the subject of debate with respect to the surgical approach. We present three cases of PPA concomitant with PTA in elderly patients. In two cases, the abscesses in parapharyngeal space were drained by abscess tonsillectomy followed by intraoral incision of the tonsillar bed. On the other hand, the third case did not undergo abscess tonsillectomy because of his refusal of surgery and needed extraoral drainage after the aggravation of PPA. Based on the experience of those three cases, it was suggested that abscess tonsillectomy followed by intraoral incision of the tonsillar bed might be a useful surgical approach for the drainage of PPA concomitant with PTA, especially in elderly patients.