Wide opening of the tract of horseshoe fistulas and high intersphincteric fistulas

Wide surgical opening of the fistulous tract is a surgical modality that has been known for a long time. Nevertheless, the method is only used on a sporadic basis, by few surgeons, owing to the large extent of postoperative wound associated with this type of surgery, and a long healing period that may be burdensome for the patient. The surgical management of horseshoe fistulas by opening the fistulous tract and thereby exposing the deep postanal space from the posterior approach, with separation of the superficial external sphincter muscle fibers, was first described by Hanley in 1965, though other surgeons also highlighted the key role of wide surgical opening and drainage of the deep postanal space. The modality is most commonly used in the treatment of horseshoe and high intersphincteric fistulas. The authors of the paper describe the method of wide opening of the fistulous tract, and outline modifications of the method reported in the literature. Transrectal ultrasound examination is recommended prior to surgery, and where the presence of high cisterns and branching is suspected, the diagnostic work-up should be extended to include pelvic MRI. The procedure is usually preceded by drainage of the main fistulous tract and branches in order to reduce infection. Various types of setons have been proposed, hence multiple modifications of the method are reported. Wide opening of the horseshoe fistula tract is an example of a bold surgical intervention, resulting in an extensive wound and associated with prolonged postoperative healing. The method represents an effective therapeutic option in patients with recurrent horseshoe fistulas involving the deep postanal space.

Reverse “Y” Shape Fistula - a Paricularity in the Evolution of Postanal Space Abscesses

Horseshoe fistula, with an incidence of less than 3% of the total perianal fistulas, is an atypical lesion not included in the classification of Parks. Its specificity is given by the anatomical features of the postanal space, respectively the presence of the anococcygeal ligament. This type of perineal fistula has a particular tract in shape of a reverse „Y”. We present the cases of 12 patient diagnosed with posterior horseshoe fistula with deep postanal space abscess surgically treated during 2013-2017. The study is retrospective and observative and it includes the history of the disease, the diagnostic methods, the surgical procedures performed and the postoperative evolution. As far as we are concerned, we based our approach on the advancement flap literature data, as well as on the role of the anococcygeal ligament in the pathology of this lesion type. After optimal control of the purulent collection from the postanal space and after the remission of local inflammatory phenomena, a correct advancement flap technique succeeds most often to resolve the septic area of the crypt of origin. We believe that current standards on the functional outcomes of these types of lesions require techniques that avoid the slow elastic cutting of the sphincter, minimizing the risk of incontinence. Keywords: postanal space abscess; anococcygeal ligament; horseshoe fistula; advancement flap