Horseshoe abscesses and fistulas: how are we doing?

Anal Cryptoglandular Suppuration: Evidence-Based Management

Anal suppurative processes are commonly encountered in surgical practice. While the initial therapeutic intervention is philosophically straightforward (incision and drainage), drainage of the appropriate space and treatment of the subsequent fistula in ano require a thorough understanding of perianal anatomy and nuanced decision making. Balancing the risk of fecal incontinence with simple fistulotomy versus the higher risk of fistula recurrence with all sphincter-sparing fistula treatments can be a challenge for surgeons and patients alike.

Intra-abdominal and Anorectal Abscesses

Intra-abdominal and anorectal abscesses are common pathologies seen in both inpatient and outpatient settings. To decrease morbidity and mortality, early diagnosis and treatment are essential. After adequate drainage via a percutaneous or incisional approach, patients need to be monitored for worsening symptoms or recurrence and evaluated for the underlying condition that may have contributed to abscess formation.

Video-assisted anal fistula treatment combined with anal fistula plug for treatment of horseshoe anal fistula

Objective

Horseshoe anal fistula is a common anorectal disease, and there is no standard procedure for its treatment. In this study, we performed a modified surgical procedure for the treatment of horseshoe anal fistula and investigated its efficacy and adverse effects.

Methods

We retrospectively analyzed the outcomes of video-assisted anal fistula treatment combined with an anal fistula plug (VAAFT-Plug) in 26 patients with a horseshoe anal fistula. The follow-up period ranged from 6 to 18 months. Preoperative and postoperative data were collected to analyze the cure rate, anal sphincter function, and incidence of complications.

Results

The surgeries were successfully performed in all patients, 23 of whom were cured (effective cure rate of 88.46%). Three patients developed recurrence and were cured after traditional surgery. No patients developed severe complications or postoperative anal incontinence. The VAAFT-Plug protocol was performed with a small incision in the fistula that subsequently promoted fistula healing and preserved sphincter function.

Conclusion

Although randomized controlled trials will be needed to fully validate these findings, our results suggest that VAAFT-Plug represents a promising treatment strategy for horseshoe anal fistulas. This technique preserves normal anal function and achieves satisfactory outcomes in most patients.

A prospective cohort study of safety and efficacy of three-cavity clearance in treatment of perianal cryptoglandular abscess

BACKGROUND

Perianal abscess is a common anorectal disease, mainly caused by anal gland infection. Abscess, once formed, should be timely treated. At present, there are many methods available to treat perianal abscess, but each of them has some shortcomings. According to the physiological and pathological mechanism of perianal abscess, we designed a new surgical method named three-cavity clearance (TCC) to maximize the protection of anal sphincter function and reduce the pain of patients.

AIM

To evaluate the safety and efficacy of TCC in perianal cryptoglandular abscess.

Methods

From January 2017 to January 2018, perianal abscess patients who underwent TCC at the Center for Anorectal Diagnosis and Treatment of the Second Affiliated Hospital of Nanjing University of Traditional Chinese Medicine were selected as a study group. Patients who underwent simple incision and drainage for perianal abscess during the same period were selected into a control group. The two groups were 1:1 paired with comparable age, sex, and abscess site. Hospitalization time, wound healing time, anal fistula formation rate, and anal incontinence were compared between the two groups.

RESULTS

There were 32 patients in each group and a total of 64 patients were included in this study. The formation rate of anal fistula in the TCC group was 6%, significantly lower than that in the control group (34.0%, P < 0.01). There was no anal incontinence in either group. The hospitalization time and wound healing time of the two groups showed no statistical difference (P > 0.05).

CONCLUSION

TCC for perianal abscess is a safe and complete anal sphincter preserving technique, which can effectively reduce the rate of postoperative anal fistula formation.

Three-cavity clearance for perianal abscess: Theoretical basis and progress in clinical application

Three-cavity clearance (TCC) is an innovative technique that completely preserves anal sphincter, which can effectively reduce the probability of postoperative anal fistula formation and the recurrence of abscess, has small trauma and a low risk, and deserves further promotion and study clinically. In this paper, we discuss the theoretical basis, clinical application, and related problems of TCC for perianal abscess.

A Rare Case of Posterior Horseshoe Abscess Extending to Anterolateral Extraperitoneal Compartment: Anatomical and Technical Considerations

Perianal abscess and fistula are 2 distinct entities that share a common pathology. A horseshoe fistulous abscess, a complex type of these conditions, occurs when the suppurative inflammation spreads through the deep anal space to the bilateral ischiorectal fossae. Following the intersphincteric plane, this infection may extend to the pararectal space, forming a supralevator abscess. We present a very rare case involving a 52-year-old male patient who was admitted to our surgical department with an extraperitoneal purulent inflammation as a complication following multiple drainage procedures for a posterior horseshoe abscess. Emphasis is given to the anatomical and technical considerations of eradication of anorectal sepsis and the management of complex fistula-in-ano along with a concise review of the literature.

Three-cavity clearance (TCC) can decrease the fistula rate after drainage of a perianal abscess: a case-control study

Objective

The aim of this study was to evaluate the safety and efficacy of three-cavity clearance (TCC) used for the treatment of perianal abscess.

Methods

A case-control study of patients with perianal abscess was conducted at the Second and Third Affiliated Hospitals of Nanjing University of Chinese Medicine from June 2013 to March 2016. Clinical data from 46 patients who had TCC were analysed. At the same time, 46 patients had simple incision and drainage and 46 patients had abscess drainage and cutting seton (radical abscess incision); the data from these patients were also analysed. The length of hospital stay, time of wound healing, fistula rate and anal incontinence were assessed.

Results

The rate of fistula formation in the TCC group was 13.0%-significantly lower than that in the group with simple incision and drainage (39.1%, p <0.01) and similar to the group with radical abscess incision (8.7%, p >0.05). Two patients (4.3%) in the group with radical abscess incision had anal incontinence, flatus and soiling; their Wexner scores were 6 and 3, respectively. There was no anal incontinence in the TCC group or the simple incision and drainage group. There were no statistical differences in the time of wound healing and length of hospital stay among the three groups (both p >0.05).

Conclusion

TCC is a safe and effective sphincter-preserving procedure for perianal abscess formation and can decrease the fistula rate after perianal abscess drainage. It appears to be a valuable method that can be used in clinical practice; however, further studies are needed to verify this finding.

Antibiotic therapy for prevention of fistula in-ano after incision and drainage of simple perianal abscess: A randomized single blind clinical trial

BACKGROUND

Much controversy exists regarding the role of antibiotics in the development of fistula in-ano after incision and drainage. We evaluated the role of postoperative antibiotics in the prevention of fistula in-ano after incision and drainage of perianal abscess.

METHODS

In a randomized single blind clinical trial study, 307 patients were randomly selected from those referring for incision and drainage of perianal abscess at Shahid Faghihi Hospital, Shiraz, Iran, during September 2013 to September 2014. Patients were allocated randomly either to receive 7 days of oral metronidazole and ciprofloxacin in addition to their standard care or to only receive standard care without any antibiotics after they were discharged from the hospital. Patients were followed for 3 months and final results were evaluated. The study was registered at the clinical trial registry (www.irct.ir; Irct201311049936n7).

RESULTS

Seven patients were lost to follow-up. Those who used prophylactic antibiotics (n = 155) had significantly lower rates of fistula formation compared with those who did not use any medication (n = 144; P < .001). Men had higher rates of fistula formation (P = .002). Patients who used more cigarettes had higher rates of fistula development (P = .001). In the univariate analysis, only postoperative antibiotic use showed a protective role against fistula formation (odds ratio = 0.426; confidence interval, 0.206-0.881). In the regression analysis postoperative antibiotic use remained protective against fistula development (odds ratio = 0.371; confidence interval, 0.196-0.703), furthermore male sex presented as a risk factor for developing fistula in-ano (odds ratio = 3.11; confidence interval, 1.31-7.38).

CONCLUSION

Postoperative prophylactic antibiotic therapy including ciprofloxacin and metronidazole play an important role in preventing fistula in-ano formation. Considering the complications of fistula in-ano formation and the minor side effects of antibiotic therapy, based on our results, a 7-10 course of postoperative antibiotics is advised after incision and drainage of perianal abscess.

Intersphincteric incision with seton at the inner opening plus contra-aperture drainage through the abscess cavity for treatment of horseshoe perianal abscess

AIM: To evaluate the safety and efficacy of intersphincteric incision with seton at the inner opening plus contra-aperture drainage through the abscess cavity for the treatment of horseshoe perianal abscess.

METHODS: Clinical data for 24 patients with horseshoe perianal abscess who underwent intersphincteric incision with seton at the inner opening plus contra-aperture drainage through the abscess cavity from January 2014 to December 2014 at the National Medical Center for Anorectal Diseases, Third Affiliated Hospital of Nanjing University of Traditional Chinese Medicine were retrospectively. Clinical recovery, recurrence during following-up, mean hospital stay time, mean time required for patients to return to work, mean cost of hospitalization, and Wexner incontinence score were evaluated.

RESULTS: The mean age of the patients was 38.42 years ± 9.59 years. During the mean follow-up period of 10.08 mo ± 3.32 mo, 17 (70.83%) cases were cured, and 7 (29.17%) developed anal fistula. Two of 7 cases of fistula were diagnosed as tuberculosis by T-Spot and underwent anti-TB treatment; one was cured, and one improved at 9 mo of follow-up. Four of the other 5 cases were cured, but one unhealed.

CONCLUSION: Intersphincteric incision with seton at the inner opening plus contra-aperture drainage through the abscess cavity has good security, less damage, short recovery time, low hospitalization costs, and good reproducibility in the management of horseshoe perianal abscess.

Innovative approach in the management of horse-shoe fistula-in-ano with Kṣārasūtra

Fistula-in-ano is a common surgical problem. Horse-shoe fistulas usually have an internal opening in the posterior midline and extend anteriorly and laterally to one or both ischiorectal spaces by way of the deep potential space. The “Śambukāvarta Bhagandara” described by Suśruta can be correlated with the horse-shoe type of fistula. In this condition, neither fistulotomy nor “Kṣārasūtra” treatment alone, are useful hence there is a need for newer innovative surgical techniques to tackle this challenging disease. An integral approach of incision and drainage of both the abscess on the arms of the horse-shoe fistula with Kṣārasūtra ligation at 6 o’ clock position proves to be successful. We have tried the same technique with good results. No recurrence was found in the patients during the follow-up period of 6 months. A 45-year-old female with a known case of diabetes mellitus and hypertension approached with both right and left ischiorectal fossa inflammatory swelling. An innovative approach was used to manage horse-shoe fistula by making an additional opening below the anus at 6 o’clock position. Apāmārga Kṣārasūtra (medicated thread made using apāmārga) was ligated through the additional opening to the internal opening at 6 o’clock position for draining through both the cavities. Kṣārasūtra was changed weekly and the fistula healed completely by 3 months.

Identification of the internal anal opening and seton placement improves the outcome of deep postanal space abscess

AIM

This study aimed to determine if successful seton placement at the initial drainage procedure improves outcomes in the management of deep postanal space abscesses.

METHOD

A retrospective review was performed of all patients who underwent initial drainage of a DPA space abscess between December 2002 and August 2010. A seton was placed through the internal opening if it could be identified.

RESULTS

Thirty-two patients of median age 41 (21-64) years formed the study group. Twenty-four (75.0%) had a seton inserted at the initial drainage procedure. The patients underwent a total of 56 operations. The median interval from the initial to the final operation was 5 (2-18) months with 17 (70.8%) patients having the final operation within 6 months. In the 8 (25.0%) patients whose internal opening could not be found, 26 operations were required with a median interval from the initial to the final surgery of 11 (3-24) months. Patients who had a seton successfully inserted at drainage underwent significantly earlier definitive surgery and required fewer operations (P < 0.038).

CONCLUSION

Identification of an internal opening with placement of a seton at the initial drainage procedure is associated with earlier definitive surgery and fewer operations.

Managing Deep Postanal Space Sepsis via an Intersphincteric Approach: Our Early Experience

Purpose

Managing deep postanal (DPA) sepsis often involves multiple procedures over a long time. An intersphincteric approach allows adequate drainage to be performed while tackling the primary pathology at the same sitting. The aim of our study was to evaluate this novel technique in managing DPA sepsis.

Methods

A retrospective review of all patients who underwent this intersphincteric technique in managing DPA sepsis from February 2008 to October 2010 was performed. All surgeries were performed by the same surgeon.

Results

Seventeen patients with a median age of 43 years (range, 32 to 71 years) and comprised of 94.1% (n = 16) males formed the study group. In all patients, an internal opening in the posterior midline with a tract leading to the deep postanal space was identified. This intersphincteric approach operation was adopted as the primary procedure in 12 patients (70.6%) and was successful in 11 (91.7%). In the only failure, the sepsis recurred, and a successful advancement flap procedure was eventually performed. Five other patients (29.4%) underwent this same procedure as a secondary procedure after an initial drainage operation. Only one was successful. In the remaining four patients, one had a recurrent abscess that required drainage while the other three patients had a tract between the internal opening and the intersphincteric incision. They subsequently underwent a drainage procedure with seton insertion and advancement flap procedures.

Conclusion

Managing DPA space sepsis via an intersphincteric approach is successful in 70.6% of patients. This single-staged technique allows for effective drainage of the sepsis and removal of the primary pathology in the intersphincteric space.

Horseshoe tract of anal fistula: bad luck or an avoidable extension? Lessons from 82 cases

AIM

The aim of this study was to analyse the characteristics of horseshoe tract formation in anal fistula.

METHOD

We retrospectively analysed the data from all consecutive patients who underwent surgery for an anal fistula from November 2004 to March 2011. A horseshoe tract was defined as a circumferential extension connecting both sides of the anorectum.

RESULTS

During the period of analysis, 1876 patients were operated on for a fistula. Of these, 82 (4.4%) had a horseshoe extension. The majority (72%) were male and the median age was 46 (17-84) years. The primary tract was high transsphincteric in 90% of cases and the primary opening was posterior in 65% of cases. The location of the horseshoe extension was posterior in 66% of cases with spread in the deep perianal space in 62%. In all, 71% were cryptoglandular and 24% were seen in Crohn's disease (20). Of the 62 non-Crohn's patients previous treatment was common and included surgery (42), antibiotics alone (41) and non-steroidal anti-inflammatory drugs (21).

CONCLUSION

Horseshoe extension in anal fistula is uncommon. With Crohn's disease excepted, the majority had had previous treatment.

Recent progress in surgical management of perianal abscess

Perianal abscess is one of the common rectal diseases. Surgical management is still the most effective way. Surgical methods have roughly experienced three phases of landmark development: initially simple incision/drainage combined with surgery for the second time when fistula-in-ano is formed, followed by primary curative incision, and finally sphincter-preserving surgery, which reinforces the importance of protecting the function of the anus. The use of these surgical methods not only reduces the recurrence of abscess and the incidence of anal fistula, but also protects the fine function and integrity of the anus, greatly reducing the pain in patients and raising their quality of lives.

Is the outcome of transanal advancement flap repair affected by the complexity of high transsphincteric fistulas?

BACKGROUND

Transanal advancement flap repair for the treatment of high transsphincteric fistulas fails in 1 of every 3 patients. Until now no definite risk factors for failure have been identified. The question is whether the more complex fistulas, such as those with horseshoe extensions and associated abscesses, have a less favorable outcome.

OBJECTIVE

Aim of the present study was to indentify whether more complex fistulas have a less favorable outcome.

DESIGN

This study is a retrospective case series review.

PATIENTS

Between 1995 and 2007 a series of 162 patients underwent endoanal MR imaging before transanal advancement flap repair. Two investigators, without prior knowledge of the surgical findings, reviewed all MR images.

RESULTS

Lateral fistulas were identified in 5 patients. Because of the small number, these patients were excluded from further analysis. Posterior fistulas were identified in 119 patients (76%). These fistulas had 3 types of extensions: a direct course (36%), a classic horseshoe extension (23%), or an intersphincteric horseshoe extension (41%). The corresponding healing rates were 37%, 81%, and 73%. Anterior fistulas were observed in 23% of the patients. These fistulas had 2 types of extensions: a direct course (61%) or a classic horseshoe extension (39%). The corresponding healing rates were 60% and 52%. The healing rate of fistulas with a direct course was significantly lower than the healing rate of fistulas with a classic or intersphincteric horseshoe extension. Associated abscesses were found in 47% of the posterior fistulas and 5% of the anterior fistulas. Once adequately drained, these abscesses did not affect the outcome of transanal advancement flap repair.

CONCLUSION

The complexity of high transsphincteric fistulas does not affect the outcome of transanal advancement flap repair.

Preliminary results on efficacy in closure of transsphincteric and rectovaginal fistulas associated with Crohn's disease using new biomaterials

BACKGROUND AND AIMS

It was the aim of this prospective study to analyze the efficacy of the Surgisis AFP anal fistula plug and the Surgisis mesh for the closure of complex fistulas in Crohn's disease.

METHODS

All patients with perianal Crohn's disease suffering from transsphincteric and rectovaginal fistulas who underwent surgery using the Surgisis anal fistula plug or the Surgisis mesh were prospectively enrolled in this study. Inclusion criteria included transsphincteric single-tract fistulas and rectovaginal fistulas. Surgery was performed using a standardized technique, including irrigation of the fistula tract, placement and internal fixation of the Surgisis anal fistula plug, and combined transanal/transvaginal excision of rectovaginal fistula with transvaginal placement of the mesh. Success was defined as closure of both internal and external (perianal or vaginal) openings, absence of drainage without further intervention, and absence of abscess formation. Follow-up information was obtained from clinical examination 3, 6, 9, and 12 months postoperatively.

RESULTS

Within the observation period, a total of 16 procedures were performed. After a mean follow-up of 9 months and 1 patient lost to follow-up, the overall success rate was 75%. For transsphincteric fistulas, the success rate was 77%, whereas it was 66% in rectovaginal fistulas associated with Crohn's disease. All 4 patients with failure had reoperation. Rate of stoma reversal in those patients who had fecal diversion was 66%. No deterioration of continence was documented.

CONCLUSION

The short-term success rates are promising. Further analysis is needed to explain the definite role of this technique in comparison with traditional surgical techniques.