INTRODUCTION
We report on a patient cohort with dorsal horseshoe fistulas-in-ano. We sought to answer the question of whether these fistulas can be operatively treated, implementing a sphincter-preserving fistulectomy with primary closure of the internal opening, as is done when treating transsphincteric anal fistulas. Long-term clinical course is examined here and operative methods are discussed.
METHODS
During the time period from 1985 to 2000, 42 patients (29 men, 13 women) with an average age of 44 ± 11 years were operatively treated for horseshoe fistulas-in-ano originating in cryptoglandular regions. Twenty patients originally had an abscess, which was surgically drained and then a seton was placed in the tract of the fistula. Later, a fistulectomy or curettage of the fistula tract with primary closure of the internal fistula opening was performed in all patients without severing the sphincter muscle. We implemented four different surgical techniques to facilitate this closure: the mucosa-submucosa advancement flap, the rectal wall advancement flap (part or full thickness), the anocutaneous advancement flap, and direct closure without any further mobilization. The follow-up averaged 58 months (1–14 years).
RESULTS
Thirty-seven of the 42 fistulas (88 percent) healed. In 31 patients, restitution occurred after the first operation, in 4 patients after the second operation and in 2 patients after the third operation. One patient developed a recurrence after the first operation and died from secondary causes before a second operation was performed. The other four patients were listed as unclear, because the time of observation was less than one year. The total recurrence rate of flap procedures is 23 percent (mucosa-submucosa advancement flap, 25 percent; rectal wall advancement flap, 35 percent; anocutaneous advancement flap, 25 percent; direct closure, 0 percent; not significant). Thirty-four (81 percent) of the 42 patients had previously been operatively treated on an average of three times. Twelve patients developed deficits in continence. Eight patients developed minor deficits, which included incontinence for flatus and problems with staining. Four patients became incontinent for liquid stools. There was a significant decrease in manometric resting pressure of 25 percent (from 123 ± 40 cm H2O to 91 ± 29 cm H2O) and in squeeze pressure of 21 percent (from 262 ± 70 cm H2O to 207 ± 66 cm H2O).
CONCLUSIONS
As in other high anal fistulas, horseshoe-shaped anal fistulas can be operatively treated implementing a fistulectomy combined with any of the above-mentioned forms of closure of the internal fistula opening, with good success rates and acceptable postoperative continence. Sufficient drainage of the retroanal region is of utmost importance. Through these measures, it is possible to avoid severing the sphincter muscle and to prevent an anal canal deformation (keyhole deformity).
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REFERENCES
H Courtney (1949) ArticleTitleThe posterior subsphincteric space Surg Gynecol Obstet 89 222–6
PH Hanley (1965) ArticleTitleConservative surgical correction of horseshoe abscess and fistula Dis Colon Rectum 8 364–8 Occurrence Handle1:STN:280:CCmD3cbpsFc%3D Occurrence Handle5830659
PH Hanley JE Ray EE Pennington OM Grablowsky (1976) ArticleTitleFistula-in-ano: a ten-year follow-up study of horseshoe-abscess fistula-in-ano Dis Colon Rectum 19 507–15 Occurrence Handle1:STN:280:CSiD3c3nt1Q%3D Occurrence Handle964108
CH Hamilton (1975) ArticleTitleAnorectal problems: the deep postanal space - surgical significance in horseshoe fistula and abscess Dis Colon Rectum 18 642–5 Occurrence Handle1:STN:280:CSmD28rmtF0%3D Occurrence Handle1192906
D Held I Khubchandani J Sheets J Stasik L Rosen R Riether (1986) ArticleTitleManagement of anorectal horseshoe abscess and fistula Dis Colon Rectum 29 793–7 Occurrence Handle1:STN:280:BiiD2sbptFw%3D Occurrence Handle3792160
K Ustynoski L Rosen J Stasik R Riether J Sheets IT Khubchandani (1990) ArticleTitleHorseshoe abscess fistula: seton treatment Dis Colon Rectum 33 602–5 Occurrence Handle1:STN:280:By%2BB1Mfntl0%3D Occurrence Handle2361430
S Athanasiadis A Koehler M Nafe (1994) ArticleTitleTreatment of high anal fistulae by primary occlusion of the internal ostium, drainage of the intersphincteric space and mucosal advancement flap. Clinical and functional long-term results in 224 patients Int J Colorect Dis 9 153–7 Occurrence Handle10.1007/BF00290193 Occurrence Handle1:STN:280:ByqC3Mvlt1Q%3D
S Athanasiadis M Nafe A Koehler (1995) ArticleTitleTransanal rectal advancement flap vs mucosal flap with suture of the internal and sphincter muscle for the management of complicated anorectal fistulas. A prospective clinical and manometric study Langenbecks Arch Chir 380 31–6 Occurrence Handle1:STN:280:ByqB38zgvFQ%3D Occurrence Handle7707848
A Koehler S Athanasiadis (1996) ArticleTitleAnocutaneous flaps as an alternative method of treatment to endorectal closure techniques in the treatment of anal fistulae – a prospective study in 31 patients Chirurg 67 1244–50 Occurrence Handle10.1007/s001040050133 Occurrence Handle9081787
AG Parks RW Stitz (1976) ArticleTitleThe treatment of high fistula-in-ano Dis Colon Rectum 19 487–99 Occurrence Handle1:STN:280:CSiD3c3ntFw%3D Occurrence Handle964106
PS Ramanujam ML Prasad H Abcarian (1983) ArticleTitleThe role of seton in fistulotomy of the anus Surg Gynecol Obstet 157 419–22 Occurrence Handle1:STN:280:BiuD2crisFA%3D Occurrence Handle6356423
HC Kuijpers (1984) ArticleTitleUse of the seton in the treatment of extrasphincteric anal fistula Dis Colon Rectum 27 109–10 Occurrence Handle6697826
CA Vasilewsky PH Gordon (1984) ArticleTitleResults of treatment of fistula-in-ano Dis Colon Rectum 28 225–31
P Sainio A Husa (1985) ArticleTitleA prospective manometric study of the effect of anal fistula surgery on anorectal function Acta Chir Scand 151 279–88 Occurrence Handle1:STN:280:BiqB2cjhvFI%3D Occurrence Handle4013605
A Christensen L Nilas J Christiansen (1986) ArticleTitleTreatment of transsphincteric anal fistulas by seton technique Dis Colon Rectum 29 454–5 Occurrence Handle1:STN:280:BimB2cnntlE%3D Occurrence Handle3720458
JG Williams DA Rothenberger FD Nemer SM Goldberg (1991) ArticleTitleFistula-in-ano in Crohn’s disease: results of aggressive surgical treatment Dis Colon Rectum 34 378–84 Occurrence Handle1:STN:280:By6B3Mrps1U%3D Occurrence Handle2022142
KP Russel JR Andrews PO Charles et al. (1993) ArticleTitleRole of the seton in the management of anorectal fistulas Dis Colon Rectum 36 573–9 Occurrence Handle8500375
J Garcia-Aguilar C Belmonte WD Wong SM Goldberg RD Madoff (1996) ArticleTitleAnal fistula surgery Dis Colon Rectum 39 723–9 Occurrence Handle1:STN:280:BymB1M%2FlsFM%3D Occurrence Handle8674361
JS McCourtney IG Finlay (1996) ArticleTitleCutting seton without preliminary internal sphincterotomy in management of complex high fistula-in-ano Dis Colon Rectum 39 55–8 Occurrence Handle1:STN:280:BymC1c7jtlE%3D Occurrence Handle8601358
JP Thomson AH Ross (1998) ArticleTitleCan the external anal sphincter be preserved in the treatment of transsphincteric fistula in ano? Int J Colorect Dis 4 247–50
L Jostarndt D Nitsche A Thiede D Schröder (1984) ArticleTitleAspects concerning the pathomorphology and therapy of anal fistulas Langenbecks Arch Chir 3 364–6
G Ozuner TL Hull J Cartmill VW Fazio (1996) ArticleTitleLong-term analysis of the use of transanal rectal advancement flaps for complicated anorectal/vaginal fistulas Dis Colon Rectum 39 10–4 Occurrence Handle1:STN:280:BymC1c7jt1M%3D Occurrence Handle8601343
WR Schouten DD Zimmermann JW Briel (1999) ArticleTitleTransanal advancement flap repair of transsphincteric fistulas Dis Colon Rectum 42 1419–22 Occurrence Handle1:STN:280:DC%2BD3c%2FjtVyjtw%3D%3D Occurrence Handle10566529
RL Nelson J Cintron H Abcarian (2000) ArticleTitleDermal island-flap anoplasty for transsphincteric fistula-in-ano: assessment of treatment failures Dis Colon Rectum 43 681–4 Occurrence Handle1:STN:280:DC%2BD3c3osVKltg%3D%3D Occurrence Handle10826431
PV Miller PJ Finan (1998) ArticleTitleFlap advancement and core fistulectomy for complex rectal fistula Br J Surg 85 108–10 Occurrence Handle10.1046/j.1365-2168.1998.00522.x Occurrence Handle1:STN:280:DyaK1c7itl2nuw%3D%3D Occurrence Handle9462397
DD Zimmermann JW Briel MP Gosselink WR Schouten (2001) ArticleTitleAnocutaneous advancement flap repair of transsphincteric fistulas Dis Colon Rectum 10 1474–80
WF Tets Particlevan JH Kuijpers K Tran R Mollen H Goor Particlevan (1997) ArticleTitleInfluence of Parks’anal retractor on anal sphincter pressures Dis Colon Rectum 40 1042–5 Occurrence Handle9293932
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Koehler, A., Risse-Schaaf, A. & Athanasiadis, S. Treatment for Horseshoe Fistulas-In-Ano with Primary Closure of the Internal Fistula Opening: A Clinical and Manometric Study. Dis Colon Rectum 47, 1874–1882 (2004). https://doi.org/10.1007/s10350-004-0650-8
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DOI: https://doi.org/10.1007/s10350-004-0650-8