Management of anorectal horseshoe abscess and fistula

Abstract

Over a 10-year period 69 patients were treated consecutively for posterior and anterior horseshoe abscesses and fistulas. Fifty-nine patients had posterior and ten had anterior abscesses or fistulas. There were 52 patients with acute abscess. Treatment consisted of incision and drainage, incision and drainage with primary fistulotomy, incision and drainage with primary fistulotomy and counter-drainage, and incision and drainage with insertion of seton. Seventeen patients with chronic fistulas were treated by primary fistulotomy with curettage, or incision and drainage with insertion of seton. Patients were followed from three months to ten years with a mean follow-up of three years. No incidences of incontinence were reported in this series. The overall rate of recurrence was 18 percent, and included only patients with posterior abscesses and fistulas. Recurrence was related to the failure to maintain prolonged drainage in the midline after primary fistulotomy. The use of seton for delayed fistulotomy appears to promote wound drainage and precludes premature wound closure. More liberal use of the seton in the treatment of horseshoe abscesses and fistulas is advocated.

Modified Hanley procedure for management of complex horseshoe fistulae

“…Our findings bear the limitations of a retrospective analysis, but are consistent with those of other authors who have reported similar data in the longer past [10,13,14,[18][19][20][21][22]. We have summarized the main findings from different studies on the utility of setons in the treatment of horseshoe fistulas in Table 1.…”

“…The original Hanley procedure which transected a relevant portion of the posterior sphincter complex has the potential of damaging the sphincter function [9], even if the original series did not identify that as a problem [7,8]. The later modification related to the use of a cutting seton (''modified Hanley procedure'') [10,13,19] to achieve the same goal over a longer period of time (staged slow-motion fistulotomy/ sphincterotomy), hence, allowing the inflammation and scar formation to preserve the anal and sphincter configuration.…”

“Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure to repair complex anal fistulas” by Piercarlo Meinero and Lorenzo Mori

“…LIFT takes note of the old observation that secondary fistula tracks will heal if they are disconnected from the principal fistula which itself is setonized, excised or repaired. Such an observation changed the management of extensive horseshoe ischiorectal abscesses in the 1980s from those large festering ischiorectal wounds that one would frequently see as a resident to the incision/counterincision procedures which would rapidly heal in most patients without incident [6]. The minimalist approach offered by VAAFT requires validation in complicated perianal Crohn's disease but it would appear that its potential value makes intuitive sense in the absence of available prospective data.…”

Incontinence rates after cutting seton treatment for anal fistula

“…13 ⁄ 21 Cox et al [36] 4 ⁄ 8 Culp [26] 3 ⁄ 20 Decanini-Terán et al [37] 0 ⁄ 42 Deshpande et al [30] 0 ⁄ 397 Durgan et al [38] 2 ⁄ 10 Dziki and Bartos [39] 12 ⁄ 32 † Fasth et al [40] 0 ⁄ 7 Flich Carbonell et al [41] 3 ⁄ 19 García-Aguilar et al [42] 8 ⁄ 12 Gonzalez-Ruiz et al [43] 0 ⁄ 31 Graf et al [44] 11 ⁄ 29 4 ⁄ 4 Gurer ‡ et al [25] 0 ⁄ 17 Hämäläinen and Sainio [45] 22 ⁄ 35 Hamel et al [46] 0 ⁄ 12 Hammond et al [47] 4 ⁄ 16 Hasegawa et al [48] 15 ⁄ 28 Held et al [49] 0 ⁄ 9 Ho et al [20] 3 ⁄ 46 † Isbister and Al Sanea ‡ [50] 17 ⁄ 47 † Joy and Williams [51] 5 ⁄ 10 Malouf et al [52] 1 ⁄ 3 McCourtney and Finlay [53] 3 ⁄ 16 Mentes et al [54] 4 ⁄ 20 Misra and Kapur [55] 0 ⁄ 53 Mohite et al [31] 0 ⁄ 114 Pescatori et al [56] 3 ⁄ 17 Qureshi et al [57] 2 ⁄ 4 Shukla et al [21] 8 ⁄ 155 Tahir § [58] 5 ⁄ 9 Theerapol et al [59] 0 ⁄ 41 Tocchi et al [60] 4 ⁄ 28 Vatansev et al [61] 5 ⁄ 32 Walfisch et al [62] 0 ⁄ 23 Williams et al [63] 8 ⁄ 13 Zbar et al [22] 3 ⁄ 34 Average rates (%) 15.9% 100% 10.5%…”