Horseshoe Abscess Perirectal

Fistulas are classified as intersphincteric, transsphincteric, extrasphincteric, and suprasphincteric. Treatment is generally surgical, except in patients with CD with active proximal intestinal disease. The goal of treatment is to cure the fistula, avoid recurrence, and preserve continence. Therefore, identification of the primary opening and side tracts and division of the least amount of muscle are the key factors for surgical success.

Horseshoe Abscess Procedure

Posterior drainage

Counter drainage

External sphincter Internal sphincter

Dentate line

FIGURE 91-1. Drainage of horseshoe abscess. Reprinted from Vasilevsky CA. Fistula in ano and abscess. In: Beck DE, Wexner SD, editors. Fundamentals of anorectal surgery, 2nd ed. London: WB Saunders;1996. p. 156. Reproduced with permission from Elsevier Ltd.

Posterior drainage

Counter drainage

External sphincter Internal sphincter

Dentate line

FIGURE 91-1. Drainage of horseshoe abscess. Reprinted from Vasilevsky CA. Fistula in ano and abscess. In: Beck DE, Wexner SD, editors. Fundamentals of anorectal surgery, 2nd ed. London: WB Saunders;1996. p. 156. Reproduced with permission from Elsevier Ltd.

Treatment options include dividing the fistula, seton placement, endorectal advancement flap, and injection of fibrin glue. For simple intersphincteric and low transphinc-teric fistulas that involve a small portion of the sphincter muscle, a fistulotomy with curettage of the granulation tissue is usually optimal.

For fistulas that involve a significant portion of anal muscle or complex fistulas, the cutting seton technique may be used. This seton is a nonabsorbable suture that is placed around the sphincter musculature at the time of surgery and tightened at regular postoperative intervals. It works by slowly cutting through the sphincter allowing the development of fibrosis, which avoids retraction of the muscles at once, as occurs with fistulotomy, and has the advantage of being a safer maneuver, although still associated with a risk of incontinence. Consequently any anoderm and anal mucosa between the seton and the sphincter muscle should be divided at the time of seton placement. If the fistula is secondary to CD, a loose (draining) seton is maintained for prolonged periods to establish drainage and prevent abscess recurrence.

The endorectal advancement flap is a good option for the treatment of high fistulas with a normal rectal mucosa. It has the advantage of closing the internal sphincter opening without dividing the anal muscle. We recently reported our experience with 106 consecutive procedures performed in 94 patients with complex perianal fistula. At a mean follow-up of 40.3 months, the procedure was successful in 60% of patients (Mizrahi et al, 2002).

Another option for fistula treatment is fibrin glue, which can be used alone or in combination with other techniques. It is associated with minimal risk and a moderate success rate. In a previous study from our institution, 33% of the patients, in whom fibrin glue was the only therapy used, were able to avoid more extensive surgery.

There are two chapters on perianal disease in CD (see Chapter 82, "Perianal Disease in Inflammatory Bowel Disease" and Chapter 83, "Dysplasia Surveillance Program").

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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