Modified Hanley procedure for management of complex horseshoe fistulae

Horseshoe fistulae are challenging due to configuration and sphincter involvement. In view of the new treatment options for fistulae (e.g. collagen plug), aim of our study was to review the outcome of patients primarily treated with a traditional approach.

We retrospectively reviewed patients who presented between 2003 and 2008, with a posterior horseshoe abscess/fistula and were treated with a modified Hanley procedure and seton management. Excluded were Crohn’s disease, fistulae from malignancy/surgical complications, and other treatment methods. Data collection included demographics, duration of the disease, and of the treatment, outcome, and incontinence.

Twenty-three patients (M/F 20/3) were analyzed. Mean age was 50.3 ± 10.2 years, median symptom duration 24 months; three patients (19%) had previously received colostomies without resolution. All patients received a posterior midline cutting seton. The average total number of setons was 3 ± 1.3 (range 2–7), with removal after 1.6 ± 1.2 months upon resolution of induration and suppuration. The cutting seton was tightened in monthly intervals on average 4.9 ± 2.2 times. Follow-up was 15.4 ± 9.7 months: 91.3% patients had complete healing time within 8.1 ± 4.5 months; 19/23 patients recovered fast, and were able to work no later than 4 weeks postoperatively (2 patients retired, 2 on disability for other reasons). No incontinence was found.

Fecal diversion alone did not resolve horseshoe fistulae. A modified Hanley procedure with drainage of the deep postanal space and cutting and draining setons proved to be safe, successful, and did not result in complaints of fecal incontinence. Completion of the treatment took months, but patients remained functional even with setons in place.