Comparison of Outcomes in Pediatric Perianal Abscess Under General Anesthesia Versus Local Anesthesia

Perianal abscess (PA) is a prevalent surgical condition in pediatric populations, particularly children under 24 months, with an estimated incidence of 0.5 - 2.3% (1-3). The definitive treatment for PA is drainage, but the choice of anesthesia, general anesthesia (GA) or local anesthesia (LA), is debated due to varying evidence regarding postoperative outcomes, recurrence rates, and procedural stress (4, 5). Studies indicate that surgical drainage under GA may reduce recurrence rates compared to LA, especially when concurrent fistulotomy is performed (4, 6). However, some research suggests that conservative management with LA can be effective, particularly in selected cases, leading to lower rates of fistula formation (7). The choice of anesthesia may also influence the child’s stress levels during the procedure, which is an important consideration in pediatric care (8).

General anesthesia provides complete immobility and effective pain control during procedures for perianal abscesses (PAs), but it is associated with risks such as respiratory complications and prolonged recovery times (9). In contrast, LA avoids systemic side effects and is generally safer, but it may be less effective in uncooperative pediatric patients, potentially resulting in incomplete drainage of the abscess (10). Recent studies have highlighted the cost-effectiveness of LA, as it often leads to shorter hospital stays compared to GA (11, 12). However, data specifically addressing pediatric outcomes with LA remain limited, making it challenging to draw definitive conclusions (4, 13). The choice between GA and LA should consider the individual patient’s needs, the complexity of the procedure, and the potential for postoperative complications.

The present study aims to compare postoperative pain, complications, and recurrence rates between GA and LA in pediatric PA drainage.

The study analyzed 426 medical records of pediatric patients (aged < 2 years) with PAs treated between 2012 and 2022. The analysis of additional socioeconomic and clinical severity factors revealed significant differences between the treatment groups (Table 1). A significantly larger proportion of patients in the GA group resided in rural areas (37.7% vs. 25.5%, P = 0.042) and had an ASA classification of II, indicating the presence of mild systemic disease (21.3% vs. 7.1%, P = 0.001). While not statistically significant, a trend was observed in caregiver employment status, with a higher percentage of unemployed caregivers in the GA group. These findings indicate that patients selected for GA generally had a higher comorbidity burden and potentially lower socioeconomic status.

The study population was stratified into two treatment groups: Group 1 (LA) comprising 85.7% (n = 365) of cases and group 2 (GA) representing 14.3% (n = 61). Recurrence analysis revealed an overall abscess recurrence rate of 24.6% (n = 105), with significantly different rates between groups: 23.3% (n = 85) in the LA group compared to 32.8% (n = 20) in the GA group (P < 0.05) (Table 2).

New abscess formation at different locations occurred in only 3.8% (n = 16) of cases (Table 3).

A statistically significant age difference was observed between the groups (P = 0.001), with the GA group being generally older than the LA group. Second, while there was no significant difference in the abscess distance from the anus between groups (P > 0.05), the abscess diameter showed a significant variation (P = 0.001), with larger abscesses more commonly associated with the GA approach. Importantly, the analysis found no gender-based differences in treatment outcomes (P > 0.05), suggesting that sex did not influence the effectiveness of either anesthesia method (Table 4).

The anatomical distribution analysis of PAs revealed distinct positional patterns among pediatric patients. As demonstrated in Table 5, the 3 o’clock position (right lateral) was the most frequent location, accounting for 23.2% of cases (n = 99), followed by the 9 o’clock position (left lateral) at 16.0% (n = 68). Together, these two locations represented nearly 40% of all abscess cases, suggesting a predilection for lateral positions in the perianal region (Table 5).

The results of multivariable logistic regression are presented in Table 6. Multivariable logistic regression analysis, adjusted for age and abscess diameter, revealed that although the overall model showed borderline statistical significance (P = 0.081), it demonstrated good fit (Hosmer-Lemeshow test, P = 0.899). In this adjusted model, LA was associated with a 34.7% reduction in recurrence risk compared to GA (adjusted odds ratio: 0.653, 95% confidence interval: 0.356 - 1.200). Although this association did not reach statistical significance (P = 0.170), the direction of the observed effect was consistent with our primary findings.

The management of PA in infants, particularly the optimal choice of anesthesia for surgical drainage, remains a persistent clinical challenge. Our study found that the recurrence rate following treatment under GA was significantly higher than under LA (32.8% vs. 23.3%). This finding initially appears contradictory to studies such as Gong et al., which reported successful outcomes with surgical management under GA (6). However, a deeper analysis of key differences in surgical philosophy and patient demographics provides a compelling explanation for this apparent discrepancy.

The most significant explanatory factor is the difference in the rate of performing "fistulotomy" as part of the surgical procedure. Studies like Gong et al., which advocate for GA, typically routinely perform fistulotomy during surgery if a fistula tract is identified (6). This aggressive approach directly eliminates the primary pathophysiological cause of recurrence (i.e., the fistula tract). In contrast, the surgical protocol in the present cohort was based on conservatism and prioritizing sphincter preservation in very young infants. Consequently, the initial intervention in the GA group was primarily limited to simple abscess drainage, avoiding systematic fistulotomy. This fundamental difference in surgical technique — drainage alone versus drainage plus fistulotomy — directly impacts the disease’s recurrence potential.

Furthermore, patient selection was another determining factor. Our data indicate that the GA group consisted of significantly older infants (mean age 3.12 vs. 1.75 months) with larger abscesses (mean diameter 8.45 vs. 7.62 mm). This suggests that surgeons intuitively selected GA for more complex cases with a higher likelihood of fistulae. Therefore, the higher recurrence rate in the GA group likely more accurately reflects the more complex nature of the disease in this specific patient subgroup, rather than an inherent flaw in the anesthetic method itself. This argument is reinforced by the systematic review by Chen et al., which concluded, based on an analysis of 1,770 infant patients, that there are minimal differences in cure and recurrence rates between conservative and surgical approaches (14). This finding suggests that the characteristics of the disease itself may contribute more to determining the risk of recurrence than merely the type of intervention.

Emerging evidence from microbiome studies provides further mechanistic insight. The research by Ma et al. revealed a specific dysbiosis in the gut microbiota of children with PA, including a reduction in beneficial short-chain fatty acid-producing bacteria (such as Blautia and Faecalibacterium) (15). Such dysbiosis can create an inflammatory environment prone to recurrence. It is possible that our GA patients, who generally had more severe cases, suffered from a greater degree of this underlying dysbiosis, predisposing them to recurrence regardless of the anesthetic or surgical technique.

Our finding that 39.2% of abscesses were located at the 3 and 9 o’clock positions aligns with the recognized anatomical pattern of anal glands (16) and emphasizes the importance of careful examination of these areas. The safety advantages of LA observed in our study, including a low and similar rate of new abscess formation (3.8% overall), avoidance of GA-associated respiratory complications (17), and lower resource requirements, support its role as an effective and efficient first-line option for simple cases in healthy infants. This finding is consistent with previous studies confirming the safety and efficacy of LA for anorectal procedures (11, 18).

Based on the integration of our findings with existing evidence, we propose a stratified management algorithm to optimize treatment outcomes. Local anesthesia should be considered the first-line treatment for simple, uncomplicated PAs in healthy (ASA I) infants under 2 - 3 months of age, offering a favorable safety profile and comparable efficacy. For more complex presentations — including large abscesses (> 8 - 10 mm), cases with complex anatomical involvement, or failure of initial LA treatment — GA remains the preferred approach. In these complex cases managed under GA, careful intraoperative assessment for fistula presence is essential, with strong consideration given to performing concurrent fistulotomy when identified to address the underlying pathology and potentially reduce recurrence risk.

To address concerns about whether the observed association between anesthesia type and recurrence could be influenced by confounding factors, we performed multivariable logistic regression analysis. Although this analysis was not statistically significant, the trend toward reduced recurrence risk in the LA group persisted even after adjusting for age and abscess size. This finding supports the hypothesis that the advantage of LA in reducing recurrence cannot be explained solely by differences in age or abscess size. The lack of statistical significance in the multivariable analysis may be attributable to the limited sample size in the GA group.