450
congenital nature [2, 3, 8], an acquired etiology is strongly
supported by some authors because of the frequent pres-
ence of local suppuration [4] and occasional spontaneous
cures.
Surgical repair by simple excision of the tract leads to a
high risk of recurrence [2, 7]. The time-h0noured vesti-
buloanal pull-through operation is unsatisfactory because
of its inadequate exposure of the operative site. Excision of
the fistula along with the anterior wall of the anorectum
below the fistula was suggested by Tsuchida et al, [7] to
avoid recurrence. The Soave type of endorectal pull-
through with ligation of the fistula at the level of the
muscular cuff [5] is an extensive procedure that does not
prevent recurrence. However, our technique of laying open
the canal provides excellent exposure of the anatomy, and
complete tract removal with subsequent anatomical and
functional reconstruction is greatly facilitated. The reposi-
tioning of the tract with the anorectum and repair of the
external sphincter and perineal body can be performed
under direct vision. The possibility of recurrence is almost
nil, and excellent functional and cosmetic results can be
expected.
References
1. Brem H, Guttman FM, Laberge GM, Doody D (1989) Congenital anal
fistula with normal anus. J Pediatr Surg 24:183 - 185
2. Chatterjee SK (1980) Double termination of the alimentary tract: a
second look. J Pediatr Surg 15:623-627
3. De Vries PA, Friedland GW (1974) Congenital "H-type" ano-urethral
fistula. Radiology 113:397-407
4. Jhang J (1984) Acquired rectovestibular fistula. Chin J Pediatr Surg
5:35
5. Spitz L, Jung PM (1980) Congenital H-type fistula of the anorectal
region. Am J Proctal Gastroenterol Colon Rectal Surg 31: 22-24,
26, 34
6. Stephens FD, Smith ED (1971) Anorectal malformations in children.
Year Book Medical Publishers, Chicago, pp 51, 64, 80, 116 - 117
7. Tsuchida Y, Saito S, Honna T, et al. (1984) Double termination of the
alimentary tract in females: a report of 12 cases and a literature re-
view. J Pediatr Surg 19:292-296
8. White JJ, Haller JA, Scott JR, et al (1978) N-type anorectal malforma-
tions. J Pediatr Surg 13:631-636