Surgical Treatment of Perianal and Perineal Hidradenitis Suppurativa* .JOSEPH P. THORNTON, M.D., HERAND ABCARIAN, M.D. HIDRADENITIS SUPPURATIVA involves the apocrine glands and is characterized by chronic recurrent sup- purative lesions in the axilla, groin, external genitalia and perianal regions. Other, less common, sites of occurrence are the nape of the neck, areola of the breasts, submammary fold, and periumbilical regio n. Hidradenitis suppurativa is not strictly germane to colonic and rectal surgery; cases have been reported by plastic surgeons, internists, dermatologists, gynecologists, urologists, and general surgeons. In this paper, a large series of patients with perianal and perineal hidradenitis suppurativa is presented in an attempt to clarify conflicting information and to es- tablish principles of surgical treatment. Materials and Methods Age (Years) From the Section of Colorz and Rectal Surge U, Cook County Hospital, and the Department of Surgery, University of Illinois Abraham Lincoln School of Medicine, Chicago, Illinois TABLE 1. Age Distribution of 104 Patients with Perianal and PeT~nealHidradenitis Suppurativa 15-20 21-30 31-40 41-50 > 50 Patients Number Per Cent The records of 104 patients with perianal and perineal hidradenitis suppurativa who were treated TOTAL by the Colon and Rectal Surgery Service at Cook County Hospital from 1972 to 1977 were studied ret- rospectively. There were 71 men and 33 women in this group, and all hut four patients were black. Seventy-eight per cent of the patients were less than 31 years of age. Conversely, only 13 per cent of the patients were more than 40 years of age (Table 1). Among the 104 patients admitted with perineal and Location perianal hidradenitis suppurativa, 59 (57 per cent) re- ported previous similar episodes. The sites of prior occur- Perianal rence were the perineum or perianal region; in 74 Groin per cent, the groin, 14 per cent, the axilla, 12 per cent Axilla (Table 2). Only 33 per cent of patients who had re- TOTAL current disease had had any type of prior treatment, which had consisted of incision and drainage with local or regional anesthesia in nearly every case. The 26 25 55 53 10 9 6 6 7 7 104 100.0 TABLE 2. Prior Episodes of Hidradenitis Supp~zrativa in 59 Patients with Recurrent Disease Patients Number Per Cent 44 74 8 14 7 12 59 100 remaining patients reported spontaneous drainage of the involved area. Two or more sites of perianal in- volvement were found in 17 per cent of the patients. * Read at the meeting of the American Society of Colon and Rectal Surgeons, San Diego, California, June 11 to 15, 1978. Address reprint requests to Dr. Abcarian: Section of Colon and Rectal Surgery, Cook County' Hospital, 1825 W. Harrison Street, Associated diseases were relatively uncommon. Di- Chicago, Illinois 60612. abetes mellitus was seen in three patients. In a 51- 0012-3706/78/1100/0573/$00.75 American Society of Colon and Rectal Surgeons 573
Transcript
Surgical Treatment of Perianal and Perineal Hidradenitis Suppurativa*
.JOSEPH P. THORNTON, M.D., HERAND ABCARIAN, M.D.
HIDRADENITIS SUPPURATIVA involves the apoc r ine glands and is character ized by chronic r ecur ren t sup- purat ive lesions in the axilla, groin, external genitalia and perianal regions. Other , less common , sites o f occurrence are the nape o f the neck, areola o f the breasts, s u b m a m m a r y fold, and periumbilical regio n. Hidradeni t is suppura t iva is not strictly ge rm an e to colonic and rectal surgery; cases have been r epo r t ed by p las t ic s u r g e o n s , i n t e r n i s t s , d e r m a t o l o g i s t s , gynecologists, urologists, and general surgeons. In this paper , a large series of patients with per ianal and perineal hidradenit is suppura t iva is p resented in an a t t empt to clarify conflicting informat ion and to es- tablish principles of surgical t rea tment .
Materials and Methods
Age (Years)
From the Section of Colorz and Rectal Surge U, Cook County Hospital, and the
Department of Surgery, University of Illinois Abraham Lincoln School of Medicine,
Chicago, Illinois
TABLE 1. Age Distribution of 104 Patients with Perianal and PeT~neal Hidradenitis Suppurativa
15-20 21-30 31-40 41-50
> 50
Patients
Number Per Cent
T h e records o f 104 pat ients with per iana l and perineal hidradeni t is suppura t iva who were t rea ted
TOTAL by the Colon and Rectal Surgery Service at Cook County Hospital f r o m 1972 to 1977 were studied ret- rospectively. T h e r e were 71 men and 33 women in this group , and all hut four pat ients were black. Seventy-eight per cent o f the patients were less than 31 years of age. Conversely, only 13 per cent of the patients were more than 40 years of age (Table 1).
A m o n g the 104 patients admi t t ed with per ineal and Location
perianal hidradenitis suppurativa, 59 (57 per cent) re- ported previous similar episodes. The sites of pr ior occur- Perianal rence were the pe r i neum or per ianal region; in 74 Groin per cent, the groin, 14 per cent, the axilla, 12 per cent Axilla (Table 2). Only 33 per cent of patients who had re-
TOTAL cur ren t disease had had any type of pr ior t rea tment , which had consisted o f incision and dra inage with local or regional anesthesia in nearly every case. The
26 25 55 53 10 9 6 6 7 7
104 100.0
TABLE 2. Prior Episodes of Hidradenitis Supp~zrativa in 59 Patients with Recurrent Disease
Patients
Number Per Cent
44 74 8 14 7 12
59 100
remain ing patients r epo r t ed spontaneous d ra inage of the involved area. Two or more sites o f per ianal in- vo lvement were found in 17 per cent of the patients.
* Read at the meeting of the American Society of Colon and Rectal Surgeons, San Diego, California, June 11 to 15, 1978.
Address reprint requests to Dr. Abcarian: Section of Colon and Rectal Surgery, Cook County' Hospital, 1825 W. Harrison Street, Associated diseases were relatively u n c o m m o n . Di- Chicago, Illinois 60612. abetes mellitus was seen in three patients. In a 51-
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5 7 4 T H O R N T O N AND
TABLe 3. Duratio'm of Symptoms in 104 Patients with Hidradenitis Suppurativa
Patients
Days Number Per Cent
0-5 62 60 6-10 18 17
> 10 24 23
TOTAL 104 100
year-old woman, the excised specimen was found to contain invasive squamous-cell carcinoma, necessitat- ing abdominoper inea l resection. A few o ther inter- cur ren t diseases were found on an incidental basis.
Durations o f symptoms are summarized in Table 3. A history o f five days or less was given by 60 per cent o f the g roup , and a n o t h e r 17 per cent had had symptoms for seven to ten days.
Surgical Technique
All patients with hidradenitis suppurat iva o f the per ineum or perianal region admit ted to the Colon and Rectal Surgery Service at Cook County Hospital are t reated by immedia te drainage o f the involved area with local anesthesia. A sample of the dra ined pus is sent for culture and antibiotic sensitivity testing (Table 4). A br ief preoperat ive work-up is completed, and the following day a definitive opera t ion is per- formed, using caudal or spinal anesthesia, with the patient in the prone jackknife position (Fig. IA). The operative p rocedure for all patients consists o f wide excision o f the involved area down to normal fat or fascia, using e lectrocautery (Fig. 1By. Wounds are packed with iodoform gauze and an occlusive dress- ing is applied. Diverting colostomy or skin grafts are not utilized routinely. The dressing and gauze pack
TABLE 4. Results of Wound Culture in Cases of Patients with Hidradenitis Suppurativa
are removed on the first postoperat ive day', the pa- tient is ambulated, and sitz baths at least four times a day are started. T h e w o u n d is covered with gauze sponges after each bath. Analgesia is main ta ined with orally adminis tered medications when necessary. T h e patient is discharged as soon as he is afebrile, com- fortable, and able to care for the wound. T h e patient is then followed in the ou tpa t ien t depa r tmen t on a biweekly basis unt i l c o m p l e t e w o u n d hea l ing is achieved (Fig. 1C).
Results
T h e average hospital stay was 7.2 days. Table 5 shows that 65 per cent o f the patients were hos- pitalized for five days or less and 80 per cent of the patients were discharged by the tenth postoperat ive day. Patients more than 40 years old, however, had an average hospital stay' o f 18.7 days.
T h e size of the wound as r ecorded on the pathol- ogy repor t was arbitrari ly assigned to one of three groups: small (2 x 2 cm), medium-sized (2-5 x 2 -5 cm) or large (more than 5 cm in any dimension). Healing time was compared with size of the wound at operat ion. Average healing times ranged f rom 3.5 weeks for small wounds to more than seven weeks for large ones (Table 6). T h e r e was no dea th in this g roup o f patients, and only' four patients were reop- erated on for r ecur rence of this condit ion in the five- year period of this study'.
Discussion
Hidradenit is suppura t iva is caused by inflamma- tion of the apocr ine glands, hence the p redominan t incidence in the perianal, perineal, axillary and in- guinal regions. T h e disease favors young adults. In the present series, the ratio o f men to women was 2:1.9 However, in a few series there have been higher incidences among women. T h e apocr ine glands func- tion after puberty, l'a and the incidence o f this disease increases in the third and four th decades of life 9 (78 per cent of patients in ou r series were less than 30 years of age).
T h e disease can be ei ther acute or chronic. In the acute stage, few deep-seated cutaneous nodules occur in an area of cellulitis. These nodules suppura t e and c o n n e c t via s u b c u t a n e o u s i n f l a m m a t o r y co rds . Should the disease go un t rea ted or t rea tment be lim- ited to incision and drainage, repea ted exacerbat ion is inevitable and will result in numerous abscesses and d r a i n i n g sinuses in a thick, c o n t r a c t e d , f ibrot ic cutaneous background, a,9 In the present series more
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FIG. 1. A (above, left). Bilateral perianal hidradeni t is sup- purativa in a 35-year-old black man.
B (above, right). Appearance of the wound immediately post- operatively, demonstrating extensive excision of all affected tissue down to normal subcutaneous fat. Diverting colostomy was not used.
C (righO. Complete wound healing, achieved in eight weeks.
576 THORNTON AND ABCARIAN
TABLE 5. Hospital Stays of 104 Patients with Hidradenitis Suppurativa
Length of Patients Stay (Days) Number Per Cent
0-5 68 65 6-10 16 15
11-20 12 12 >20 8 8
TOTAL 104 t00
than half of the patients had r ecu r ren t episodes o f hidradenitis and of these patients, 74 per cent had recur ren t infections in the perianal a rea .
Various modalities o f therapy have been recom- m e n d e d for hidradenit is suppurativa. Verneui l n is credi ted with r e c o m m e n d i n g incision and dra inage o f the f luctuant area as suppura t ion is f requent ly the complaint for which the patient seeks t reatment . Even now Verneui l ' s m e t h o d is the most c o m m o n , al- t hough some have resor ted to t r ea tmen t t h r o u g h diet, heat, ultraviolet irradiation, vaccination, steroids and antibiotics, all with poor resuhs. 9' 10.12
Good success with surgical excision o f the affected areas was r epor t ed by Lane r in 1933. Since that re- port, others have advocated early, aggressive surgical excision of all affected areas. ''a'9,10 Following surgical excision, the open wound can be t rea ted in three ways. 1) pr imary closure with or without skin flaps; 2) split-thickness skin graft ing; 3) leaving the wound open and allowing it to close by secondary granula- tion and epithelialization.
P r ima ry c losure is usual ly sui table fo r a small wound located in a relatively clean area, i.e., the axilla. Simple closure, Z-plasty and o ther flap techniques have been described, s,9 A few successful cases o f pri- ma ry c losure a f t e r excis ion o f h id r aden i t i s sup- purat iva o f the groin or p e r i n e u m have been re- ported. 1'2'1~ However , most investigators agree that because o f the c o n t a m i n a t e d e n v i r o n m e n t , open per ineal wounds should not be closed primari ly. 9 Ching and Stahlgren r epo r t ed a few cases o f split- thickness skin grafting with good results, but Knaysi et
al. 6 had poor results when this technique was used in the groin and perineal areas. Conway et al. 3 advocated split-thickness skin graf t ing o f the open wound to prevent scar format ion. This appears to be more ap- p ropr ia te for the axilla. T h e results of o u r s tudy
Fro. 2. A (/eft). Hidmdenitis suppurativa in a 63-year-old black woman with extensive perianal, perineal, vulvar and inguinal involvement. (B) (right). Operative photograph, showing the extensive excision of all diseased areas. A diverting colostomy was made in this case.
Volume 21 N u m b e r 8 SURGERY FOR HIDRADENITIS SUPPURATIVA 577
s t r o n g l y s u p p o r t those o f L e t t e r m a n a n d S c h u r t e r , 8 Vicke r s v' a n d Masson 9 in tha t r a p i d h e a l i n g a n d ex- ce l l en t resu l t s can be a c h i e v e d by p a c k i n g the p e r i n e a l w o u n d s o p e n to hea l with s e c o n d a r y g r a n u l a t i o n . In o u r se r ies the c o n t r a c t u r e s o f the w o u n d s we re min i - real a n d the p e r i n e u m was p l iab le a n d n o n t e n d e r . T h e a v e r a g e hosp i t a l stay o f seven days in o u r ser ies also c o m p a r e s f a v o r a b l y with the m e a n 12 days re- p o r t e d by V i c k e r s ? 2
R o u t i n e an t ib io t ics a n d skin g r a f t i n g we re no t u sed in o u r series. In ten o f 13 pa t i en t s (76) m o r e t h a n 40 yea r s old , h i d r a d e n i t i s s u p p u r a t i v a was qu i t e e x t e n - sive, a n d the r e s u h a n t w o u n d s we re ve ry l a rge (Fig. 2A ). H o w e v e r , c o n t r a r y to C h i n g a n d S t a h l g r e n ' s rec- o m m e n d a t i o n for r o u t i n e colostomy,'- ' d i v e r t i n g colos- t o m y was used in only' o n e pa t i en t , an e lde r ly , obese w o m a n with l a rge a r e a s o f p e r i n e a l exc is ion , who was e x p e c t e d to be d i f f i cu l t to a m b u l a t e p o s t o p e r a t i v e l y for f r e q u e n t sitz b a t h s (Fig. 2B). All o f the o t h e r pa- t ien ts h a d n o r m a l , in tac t ana l cana ls a n d were easy to a m b u l a t e ; they were t r e a t e d w i thou t a d i v e r t i n g colos- tomy.
F ina l ly , one case o f invas ive s q u a m o u s - c e l l ca r - c i n o m a was s een in a p a t i e n t w h o h a d h a d h id - radeni t i s suppura t iva for m o r e than 20 years. A s imilar case has be~n r e p o r t e d by D o n s k y a n d M e n d e l - son, 4 a n d J a c k m a n , s in r e v i e w i n g 125 cases o f c h r o n i c h i d r a d e n i t i s s u p p u r a t i v a f o u n d f o u r p a t i e n t s wi th s q u a m o u s - c e l l c a r c i n o m a fo r an i n c i d e n c e o f 3.2 p e r cent . T h a t all pa t i en t s wi th invas ive s q u a m o u s - c e l l c a r c i n o m a had h a d h i d r a d e n i t i s s u p p u r a t i v a fo r m o r e t h a n 20 years s t resses t he n e e d fo r ea r ly excis ion.
C o n c l u s i o n
O n e h u n d r e d f o u r pa t i en t s who h a d p e r i a n a l a n d p e r i n e a l h i d r a d e n i t i s s u p p u r a t i v a we re t r e a t e d wi th ear ly , ex tens ive a n d c o m p l e t e surg ica l exc i s ion ; long- t e r m resul t s were exce l l en t , hosp i t a l stays we re shor t ,
a n d the r e c u r r e n c e r a t e was low. All w o u n d s we re a l l owed to hea l by s e c o n d a r y g r a n u l a t i o n . No an t ib i - otics we re a d m i n i s t e r e d , t h e r e was no sp l i t - th i ckness
TABLE 6. Relationship of Wound Size to Wound Healing Time
Incidence Healing Time Size (Per Cent) (Weeks)
Small (2 x 2 cm) 20 3.5 Medium (2-5 x 2-5 cm) 58 5 Large (more than 5 cm 22 7
in any dimension)
skin g r a f t i ng , a n d a d i v e r t i n g c o l o s t o m y was used in
only o n e pa t i en t .
R e f e r e n c e s
1. Chalfant WP, Nance FC: Hidradenitis suppurativa of the perineum: Treatment by radical excision. Am Surg 36:331, 1970
2. Ching CC, Stahlgren LH: Clinical review of hidradenitis sup- purativa: Management of cases with severe perianal in- volvement. Dis Colon Rectum 8: 349, 1965
3. Conway H, Stark RB, Climo S, et al: The surgical treatment of chronic hidradenitis suppurativa. Surg Gynecol Obstet 95: 455, 1952
4. Donsky HJ, Mendelson CG: Squamous cell carcinoma as a complication of hidradenitis suppurativa. Arch Dermatol 90: 488, 1964
5. Jackman RJ: Hidradenitis suppurativa: Diagnosis and surgical management of perianal manifestations. Proc R Soc Med Suppl 52: 110, 1959
