A Review on Treating Postoperative Perianal Abscess by the TCM External Therapy

LV Bo-lin (吕博琳), FENG Wen-zhe (冯文哲), WANG Yao (王 耀), ZHAO Shen (赵 申)

1. Shaanxi University of Chinese Medicine, Xianyang 712000, China

2. The Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang 712000, China

ABSTRACT Perianal abscess is a common clinical disease. This disease progresses rapidly. Surgical treatment is the main clinical treatment. Postoperative pain, bleeding, and excessive exudate are often accompanied by slow postoperative wound healing due to special anatomic site. The external treatment of traditional Chinese medicine has various treatment methods for perianal abscess after operation, and the results are quite effective. The treatment experience of various doctors in the past five years was summarized as follows.

KEYWORDS Postoperative perianal abscess; Dressing change on wound; Fumigation; Moxibustion;Acupuncture; Ear points; Acupoint application; Reviews

Perianal abscess is called "anal carbuncle"in traditional Chinese medicine, and it is mainly manifested as local pain and swelling around the anorectum, which may be accompanied by fever. It can be seen in any age group, with a high incidence for 20-40 years old, and the incidence rate of male is higher than that of female[1]. The disease has a rapid onset. At present, the treatment of perianal abscess is usually based on surgery. However,due to the special anatomy position of the anus,the openness of the postoperative wound, and the surgical incision are often larger and deeper,there are more tissue damages, and it is easy to be complicated with anal pain, edema and more exudation, etc. The postoperative wound is easily contaminated by excrement, and wound infection is prone to occur. The treatment of perianal abscess in modern medicine includes anti-infection, wound disinfection, drainage and aseptic dressing. Longterm antibiotic application and wound disinfection are prone to medicine-resistant flora and flora disorders, and complications such as anal itching may delay the wound healing and affect quality of life of patients[2-3]. In recent years, various external treatments of traditional Chinese medicine have gradually highlighted their advantages in the application of perianal abscess surgery. The application of external Chinese medicine treatments in the past five years after perianal abscess surgery has been summarized.

DRESSING FOR WOUNDS

YANG S[4]and others used compound Huanglian Ointment (复方黄连膏) gauze to change dressing (Radix Lithospermi,Myrrha,Margarita,Radix Angelicae Sinensis,Sanguis Draconis,Olibanum,Rhizoma Bletillae,Radix Angelicae Dahuricae,Rhizoma Coptidis,Borneolum Syntheticum, vaseline, etc.) for patients with perianal abscess after surgery. The control group was changed with vaseline gauze. Observation and comparison between the two groups showed that the postoperative pain disappearance time,wound healing time, and wound granulation tissue state in the observation group were better than the control group (P＜0.05), and the clinical effect was significant. SONG CM[5]et al. used Jingwanhong Ointment (京万红软膏) to promote blood circulation and flesh growth in wound dressing and at the same time cooperate with the method of removing wound flesh to treat patients with perianal abscess.Compared with purely using Jingwanhong Ointment for wound dressing, the total effective rate was significantly improved (P＜0.05), and the wound healing time was significantly shortened (P＜0.05).CHEN T[6]et al. provided basic antibacterial and potassium permanganate (1:5 000) sitz bath therapy to patients with perianal abscess after surgery.Randomized controlled trials were conducted on this basis. Doxycycline-physiological sodium chloride solution (1:1) gauze dressing was changed in the control group, and the treatment group used Kubai Oil (苦柏油) [Radix Sophorae Flavescentis30 g,Cortex Phellodendri25 g,Spina Gleditsiae(皂角刺) 15 g,Rhizoma Coptidis15 g,Radix Paeoniae Rubra15 g,Radix Angelicae Dahuricae15 g,Radix Sanguisorbae15 g,Radix Glycyrrhizae10 g]gauze dressing, and then apply healing oil (Sanguis Draconis30 g,Margarita25 g,Radix Angelicae Sinensis15 g,Olibanum15 g,Myrrha15 g,Rhizoma Bletillae15 g,Catechu10 g) dressing change in the subsequent granulation tissue stage and epithelial growth stage. The course of treatment was 4 weeks. The results showed that the cure rate in the treatment group reached 80%, and that in the control group was 63.3%. The reduction rate of the wound area in the treatment group was significantly higher than that in the control group (P＜0.01). The treatment group was significantly lower than the control group in terms of carrion shedding time and wound healing time (P＜0.05). The treatment group was better than the control group in terms of VAS pain scores, wound secretion score and granulation tissue growth score (P＜0.05). WU Q[7]et al. gave routine treatment to patients with perianal abscess undergoing one-time radical resection, with selfmade Kubai Oil gauze dressing (自拟苦柏油纱条换药). After 15 days, the healing-promoting gauze was replaced with dressing change. In this method, the pain feeling, wound edema, exudation conditions were significantly improved. ZHANG Y[8]applied Lianchuang Powder (敛创散) (Halloysitum Rubrum20 g,Os Draconis20 g,Borneolum Syntheticum20 g,Sanguis Draconis30 g,Myrrha30 g, elephant skin 30 g,Olibanum6 g,Catechu9 g to ground into powder). The method of coating the wound with sterile gauze cover was used to treat patients after perianal abscess suture surgery. The effective rate was 92.95%, and the serum inflammatory factors TNF-α, IL-6, IL-8 and CRP levels were significantly reduced, and the effect was significant (P＜0.01),and effectively accelerate wound healing, promote granulation tissue hyperplasia, reduce wound edema and reduce wound secretions (P＜0.01).GE GD[9]et al. used Shengji Hongfen Ointment (生肌红粉膏) for wound dressing [Shengji Yuhong Ointment (生肌玉红膏) plus 15% red powder], and then used Shengji Yuhong Ointment for wound dressing after the slough on the wound surface. The course of treatment was 4 weeks. Shengji Hongfen Ointment can effectively promote the shedding of slough on the wound surface, and when used with Shengji Yuhong Ointment, it can obviously promote wound healing and reduce wound pain and edema. WANG J[10]et al. usedRadix Lithospermioil gauze strips combined American cockroach powder for wound dressing, 2 times a day. This method significantly reduced wound pain, effectively promoted wound granulation tissue growth, reduced wound secretions, and the number of patients with postoperative complications of perianal eczema has been significantly reduced.

Wound dressing change after perianal abscess operation can keep the medicine and wound stick together for a long time, and increase the ability of local medicine on the wound. The medicines used by doctors to change the dressing of such patients are mainly for clearing heat and promoting blood circulation, removing decay and promoting flesh growth. Among them,Radix Lithospermi,Sanguis Draconis,Olibanum,Myrrhawere used frequently. Modern experimental studies suggest thatRadix Lithospermican achieve anti-inflammatory,antioxidant and anti-inflammatory, and anti-tumor effects by inhibiting serum NF-κB, IL-6, IL-22,TNF-α, epidermal growth factor, etc.[11-13].Sanguis Draconishas the effects on activating blood to stop bleeding, resolving blood stasis and relieving pain, condensing sores and generating flesh. The laboratory has proved thatSanguis Draconiscan promote blood circulation and removing blood stasis by reducing hematocrit, plasma viscosity,and whole blood viscosity. By influencing platelet aggregation and endogenous coagulation factors,hemostatic effect was achieved to promote fibroblast proliferation and vascular epidermal growth factor to achieve astringent sores and flesh growth[14-16];OlibanumandMyrrhawere commonly used to promote blood circulation and relieve pain, reduce swelling and promote flesh growth. When the ratio of the two medicine is 1:1, the synergy is strongest[17].Experiments have shown that both show significant anti-inflammatory, analgesic, anti-tumor and blood coagulation effects.Myrrhaalso has a certain neuroprotective effect[18-19].

CHINESE MEDICINE FUMIGATION

HUANG X[20]et al. used a randomized controlled method to compare treatment of 60 patients with perianal abscess of damp-heat diffusing downward syndrome. After conventional treatment and dressing change, the experimental group used Cuyu Kushen Decoction (促愈苦参汤) (Radix Sophorae Flavescentis30 g,Herba Taraxaci30 g,Radix et Rhizoma Rhei30 g,Cortex Phellodendri30 g,Radix Scutellariae30 g, andGalla Chinensis30 g, water decoction 200 mL)for ultrasonic atomization fumigation. The control group was given ultrasonic atomization fumigation with potassium permanganate solution (1:5 000,200 ml). Compared with the control group, the average disappearance time of complications was shortened in the experimental group (P＜0.01), and the wound healing time was shortened (P＜0.01).The total effective rate in the experimental group was 96.67% and that in the control group was 76.67%. The comparative results proved that the ultrasonic atomization fumigation of Cuyu Kushen Decoction effectively reduces complications and promotes wound healing after perianal abscess surgery. CHEN Ming-tong[21]et al. used Baiji Shengji Decoction (白及生肌汤) (Rhizoma Bletillae30 g,Rhizoma Curcumae Longae30 g,Semen Persicae30 g,Caulis Sargentodoxae30 g,Radix Angelicae Sinensis20 g,Radix Scrophulariae20 g,Fructus Gardeniae20 g,Radix Aucklandiae20 g,Cortex Moutan Radicis20 g,Fructus Schisandrae Chinensis20 g,Cortex Ailanthi20 g, andGalla Chinensis20 g) for fumigation twice per day to treat postoperative patients with perianal abscess.Baiji Shengji Decoction had obvious advantages in wound pain and granulation tissue growth compared with potassium permanganate (1:5 000) fumigation(P＜0.05). Baiji Shengji Decoction (白及生肌汤) has the effects on promoting blood circulation, promoting Qi, relieving pain, astringent and promoting flesh growth. ZHOU J[22]used Chinese medicine fumigation and washing (Cortex Phellodendri20 g,Radix Angelicae Dahuricae20 g, friedRhizoma Atractylodis20 g,Herba Taraxaci20 g,Rhizoma Acori Tatarinowii20 g,Radix Sophorae Flavescentis40 g,Radix et Rhizoma Rhei40 g,Cortex Dictamni15 g,Rhizoma Polygoni Cuspidati15 g,Flos Lonicerae15 g) to treat perianal abscess after surgery, 2 times a day, 15-20min/time, continuous use for 14 days. Compared with potassium permanganate (1:5 000) fumigation, the effective rate of traditional Chinese medicine fumigation was 96.67%, and the wound healing time, edema,swelling pain and wound exudate disappearance time were shorter than potassium permanganate fumigation (P＜0.05). BI XK[23]used a randomized controlled trial method to compare the treatment of postoperative patients with perianal abscess.The control group was treated with potassium permanganate (1:5 000) and the observation group was treated with Jiawei Kushen Decoction (加味苦参汤) (Radix Scutellariae30 g,Flos Lonicerae30 g,Radix Sophorae Flavescentis30 g,Rhizoma Acori Tatarinowii15 g,Fructus Cnidii15 g,Fructus Schisandrae Chinensis15 g) fumigation, sitz bath after 15 min fumigation, 2 times a day, and the course of treatment was 2 weeks. The results showed that the effective rate in the observation group was 93.33%, and the effective rate in the control group was 73.33%. The length of hospitalization and wound healing time in the observation group were shorter than the control group (P＜0.05), and the fumigation and washing of Jiawei Kushen Decoction could more reduce serum IL-6 and CRP level (P＜0.05).For patients after a one-time radical resection of low perianal abscess, CHEN J[24]treated with Kangfuxin liquid (康复新液) fumigation and washing for 15 minutes and then theRadix Scutellariaeointment gauze strip was changed. After fumigation and washing with potassium permanganate (1:5 000) and nitrofural gauze dressing change as a control, the course of treatment was 10 days. The results showed that the incision healing time, pain disappearing time and wound fresh granulation tissue coverage time in the treatment group were shorter than those in the control group (P＜0.05). WANG SX[25]and others used randomized controlled trials to compare and observe patients after primary incision and radical resection of perianal abscess. The control group used (1:5 000) potassium permanganate (1:5 000)routinely changed the dressing after bathing, and the treatment group used self-made Qingre Jiedu lotion (清热解毒洗剂) [Herba Taraxaci(蒲公英)20 g,Radix Angelicae Sinensis20 g,Galla Chinensis20 g,Rhizoma Polygoni Cuspidati20 g,Natrii Sulfas20 g,Radix Astragali seu Hedysari30 g,Radix et Rhizoma Rhei30 g,Cortex Phellodendri30 g,Radix Scutellariae30 g,Flos Lonicerae30 g,Pericarpium Zanthoxyli30 g,Radix Glycyrrhizae15 g, with modification] for fumigation and washing and dressing change. The effective rate was 94.9%,and Qingre Jiedu lotion significantly reduced the pain and wound edema (P＜0.05), and the incidence of complications and recurrence rate were also significantly lower than the control group (P＜0.05).JI Z[26]and others applied Qingre Qudu prescriptions(清热祛毒方) (Olibanum15 g,Myrrha15 g,Radix Angelicae Dahuricae15 g,Radix Angelicae Sinensis15 g,Radix Saposhnikoviae15 g,Radix Stemonae15 g,Radix Glycyrrhizae15 g,Herba Taraxaci20 g,Rhizoma Coptidis20 g,Cornu Bubali20 g,Cortex Phellodendri20 g,Radix Sophorae Flavescentis20 g) fumigation for patients who were treated after a one-time incision radical perianal abscess operation, 2 times a day, fumigating for 15 minutes and then sitz bath for 20 minutes. The course of treatment was 25 days. Compared with the potassium permanganate (1:5 000) fumigation and washing bath, the comparison showed that Qingre Qudu prescription (清热祛毒方) fumigation and sitz bath has a good effect, significantly accelerated the shedding of rotting flesh on the wound, promoted the growth of new epithelium, and accelerated wound healing (P＜0.05). The fumigation and washing of Qingre Qudu prescription were superior in terms of symptoms and signs, recurrence and complications(P＜0.05). YE DB[27]et al. used Xianfang Huoming Decoction (仙方活命饮) fumigation and washing to treat patients with perianal abscess after surgery.Compared with potassium permanganate (1:5 000),the Xianfang Huoming Decoction fumigation and washing group had faster wound healing and the aspects of painful wounds, exudation, granulation tissue growth was superior, and can effectively reduce serum inflammatory factors TNF-α and IL-6 levels. FENG L[28]et al. implemented basic antibacterial treatment and potassium permanganate(1:5 000) fumigation and washing for patients with perianal abscess after surgery. The experimental group was fumigated with Chinese medicine (Radix Astragali seu Hedysari50 g,Flos Lonicerae9 g,Radix Saposhnikoviae6 g,Bulbus Fritillariae Thunbergii6 g,Radix Angelicae Sinensis6 g,Spina Gleditsiae6 g,Radix Paeoniae Rubra6 g,Radix Trichosanthis6 g,Myrrha6 g,Radix Glycyrrhizae6 g,Pericarpium Citri Reticulatae9 g)for 20min followed by application of medicinal gauze compression for 30 minutes. Under this treatment method, the wound healing of the patient was accelerated. The redness and swelling of the wound were obviously reduced, and the sloughing off was accelerated. The secondary infection and recurrence rate were low.

The Chinese medicine fumigation and washing method is fumigation and sitz bath. The warm liquid can promote the local circulation of the wound tissue. The heat can dilate the local capillaries, promote the absorption of the medicine and enhance the local effect of the medicine. The doctors choose prescriptions to clear away heat and detoxify, dry dampness, and promote blood circulation. A combination of analgesic prescriptions and medicines is used for fumigation and washing treatment. Among the various medicine,Radix Sophorae Flavescentiswas the most used.Radix Sophorae Flavescentishas good anti-inflammatory and immune-adjusting anti-allergic effects, and can inhibit human scar fibroblasts[29-30]. Appropriate amount ofRadix Sophorae Flavescentiscan be added to clinical fumigation and washing prescriptions to reduce wound edema and exudate and promote wound healing.

MOXIBUSTION

SONG LC[31]used routine debridement and disinfection combined with 20 minutes of wound moxibustion to treat postoperative perianal abscess.Compared with infrared radiation, the patient's wound pain scores and wound exudate scores were better than those in the infrared radiation group. The granulation tissue growth score in the observation group on the 14thand 21stday was better than the infrared irradiation group (P＜0.05). LIU T[32]also used wound moxibustion to treat perianal abscess after surgery. After routine wound dressing was changed, the treatment group received wound moxibustion for 30 minutes, and the control group received microwave irradiation for 30 minutes for 7 days. The results showed that the wound healing time in the treatment group was shorter (P＜0.05).VAS and VRS in the treatment group were better than the control group (P＜0.05), which effectively promoted wound healing and relieved pain.

Moxibustion has the effects on Fuzheng Quxie(扶正祛邪), and moving qi and blood. Modern medicine suggests that the infrared spectrum effect of moxibustion can promote tissue microcirculation,resist free radicals, expand blood vessels, increase metabolic rate, and promote tissues repair by promoting cell proliferation and collagen fiber growth[33-34]. Moxibustion on the wound after the operation of perianal abscess can effectively reduce the pain and exudation of the wound, promote tissue repair, and shorten the healing time of the wound.

ACUPUNCTURE

XING YT[35]used conventional dressing change in combination with acupuncture. After routine dressing change, Dachangshu (BL25), Changqiang(DU1), Erbai (EX-UE2), Chengshan (BL57) and Sanyinjiao (SP6) were taken for acupuncture.The needles were retained for 20 minutes, and acupuncture was performed every 15 minutes.Pain was significantly reduced after acupuncture,the levels of immunoglobulin and neutrophils were significantly increased, and the immune function returned to normal.

JIN HY[36]used transcutaneous electrical acupoints stimulation to treat patients with perianal abscess after surgery. Under the premise of basic treatment, Dachangshu (BL25) and Baihuanshu(BL30) were selected, the density wave 2/100 Hz,30 min/time, 2 times/day. Under this treatment, the β-endorphin level of the patient was significantly increased, which effectively relieved the pain of the patient's wound.

EAR ACUPUNCTURE

ZHOU WY[37]and others applied ear acupuncture [Shenmen (TF4), Dachang (CO7),Jiaogan (AH6a), etc.] for patients with perianal abscess after surgery. The treatment course was one week. The results showed that this method can effectively reduce the patient's pain, improve local perianal blood supply, and accelerate inflammation absorption. XIE W[38]et al. used ear acupoint pressing method [Shenmen (TF4), Pizhixia (AT4),Anus (肛门), Neifenmi (CO18), Jiaogan (AH6a),Ashi point (HX5)]. Pressing was performed 4-6 hours after operation, 1 min/time/point, every 6 hours, and keep pressing during dressing change.This operation effectively reduces the patient's pain and pain during dressing change, and reduces the application of analgesics during treatment.

Ear acupoints stimulation has the effects on dredging the meridians, regulating viscera, and moving qi and blood. The pressing of related ear acupoints can stimulate related sensitive points and directly exert an analgesic effect.

EMBEDDING AND ACUPOINTS APPLICATION

CUI ZY[39]used meridian triple therapy, namely,catgut embedding at Baihuan (BL30) and Ciliao(BL32); closed vitamin B12at Changqiang (DU1).Acupoints application at Shenque (RN8) and Zusanli(ST36) (Rhizoma Sparganii30 g,Rhizoma Corydalis30 g,Rhizoma Curcumae25 g,Rhizoma Ligustici Chuanxiong12 g,Pericarpium Citri Reticulatae9 g, etc.), retained for 12 hours, and the course of treatment was 7 days. The patient's VAS score,anal marginal edema, and postoperative urinary retention were significantly improved under the implementation of this method (P＜0.05). ZHAO YJ[40]et al. used acupoint water acupuncture and thread embedding to routinely disinfect Changqiang (DU1),followed by catgut embedding, and then injected methylene blue. This method effectively relieves patients' pain and postoperative urinary retention.

The thread-embedding method can continuously stimulate of acupoints to achieve longterm analgesia[41], and has the effects on regulating neurotransmitters, enhancing tissue metabolism,and regulating immunity[42]. Acupoints application can make the medicine form a continuous effect on the corresponding acupoints to promote qi and blood circulation to relieve pain. InZhenjiu Yulongjing(＜＜针灸玉龙经>>), "Nine types of hemorrhoids hurt the most...the one who suffered with great pain,a needle could end disease root"; InSheng Yu Ge, "Hemorrhoids intestinal wind was treated by Changqiang (DU1)". The anatomy of Changqiang(DU1) involved the anal nerve, tail nerve and pudendal nerve branch, and continuous stimulation of Changqiang (DU1) can effectively improve the perianal pain[43-44].

CONCLUSION

With the development of society, the diet of the general public has changed. Eating fat and sweet, spicy and stimulating products, drinking and irregular work and rest can produce phlegm and dampness, accumulate heat and toxins, and phlegm and dampness will not dissolve, accumulation transforms into heat toxins. Anal carbuncle caused by heat and dampness on the lower Jiao (下焦).In Plain Conversation·Major Discussion on the Progress of the Six Climatic Changes: "The burst due to stagnation of fire... Under such as condition, people are susceptible to shortness of breath; sores, ulcers, carbuncles and swelling." The treatment of anal carbuncle in traditional Chinese medicine should be based on the corresponding prescription with syndrome differentiation. However,with the development of modern medicine, surgical treatment has become the preferred treatment for anal carbuncle. However, the postoperative dressing change period is long and the wound healing is slow, which affects the quality of life of patients.The various external treatment methods of Chinese medicine have certain advantages in the treatment of patients at this stage, and the external treatment methods of Chinese medicine by various physicians have achieved great results. Wound dressing change and Chinese medicine fumigation can make traditional Chinese medicine directly act on the wound. Through continuous action on the wound and fumigation and expansion of local capillaries,the Chinese medicine can better act on the wound,promote blood circulation, relieve pain and generate flesh. Moxibustion on the wound achieves the function of warming and nourishing qi and blood.Auricular points, acupuncture and acupoints application can promote Qi and relieve pain through overall adjustment. The above-mentioned treatment methods are safe and effective, and the operation is simple and easy to implement, which effectively promotes wound healing after perianal abscess surgery and reduces wound pain, edema and wound exudation. There are many literature reports and related systematic analysis on Chinese medicine fumigation and dressing of wounds, and the clinical feasibility is relatively high. However, there are fewer literature reports on moxibustion, acupuncture auricular points, thread embedding, and acupoints application, and more scientific research is needed to verify the feasibility of clinical examination.