Fistulotomy and Setons

Mr Graham Williams

Consultant Colorectal Surgeon

Royal Wolverhampton Hospitals NHS Trust

Surgical Treatment of Anal Fistulas

Anal Fistula

•Eradicate fistula

•Maintain continence

Aims of Surgical Treatment

Author Date Number Recurrence

Hill 1967 626 6 (1%)

Ani & Solanke 1976 82 14 (17%)

Kuijpers 1982 51 2 (4%)

Gingold 1983 74 1 (1%)

Kronborg 1985 26 3 (11%)

Lilius 1986 150 8 (5.5%)

Shouler 1986 115 8 (7%)

Anal Fistula SurgeryResults of Fistulotomy

Anal Fistula SurgeryProblems Following Fistulotomy

• Extensive wound & delayed healing• Gutter / key hole deformity• Anal incontinence

–Flatus (10% - 20%)–Soiling (5% - 10%)–Urgency–Faecal incontinence

Anal Fistula SurgeryWhen is it Safe to Lay Open

A

DC

B

Anal Fistula SurgeryWhat is a High Fistula

• Sphincter muscle involved

• Site (anterior vs posterior)

• Male or female

• Previous anorectal surgery

• Associated diseases (eg Crohn’s)

Anal Fistula SurgerySeton Techniques

• As a marker of the tract

•As a long-term drain• Two stage fistulotomy• Snug seton (long-term cutting)

•Tight seton (cutting)

Anal Fistula SurgeryResults of Loose Seton

• 34 patients with high transsphincteric fistulas• Loose nylon seton inserted• Seton removed when external wound healed• 15 (44%) healed without further treatment

– 10/12 (83%) remained fully continent

• 19 patients underwent completion fistulotomy– 5/16(32%) remained fully continent

Thomson & Ross Int J Colorect Dis 1989

Loose SetonLong term Results

0

5

10

15

20

6 months >10 years

20

4

13

20

Total

Free of Sepsis

Num

ber

of P

atie

nts

Buchanan et al, St mark’s Hospital, BJS 2004

Anal Fistula SurgeryResults of Cutting Seton

Author Healing %

Recurrence %

Incontinence %

Williams et al 100 0 45

Pearl et al 97 3 --

McCourtney & Finlay

96 4 --

Hamalainen et al

94 6 63

Garcia Aguillar et al

92 8 50

Dzihi et al 100 0 38

Seton FistulotomyCutting v Two Stage

MinneapolisData

Cuttingn = 12

Two-Stagen = 47

Recurrence 1 (8%) 4 (8%)

Incontinence 8 (75%) 31 (66%)

Score (0-21) 4.9 4.2

Satisfied 11 (92%) 40 (85%)

Garcia-Aguilar et al 1998. BJS

0

2

4

6

8

10

12

14

16

18Total

Healed

Loose seton Cutting seton

NU

MB

ER

Fistula Healing

Outcome of Anal Fistula SurgeryResults - Clinical Review

75%

96%

12

17

Wolverhampton Data, Joy & Williams, Colorectal Dis 2002

0

5

10

15

20

25

Total

“Full Control”

Loose seton Cutting seton

NU

MB

ER

Continence

Outcome of Anal Fistula SurgeryResults - Clinical Review

91%

94%23

17

Wolverhampton Data, Joy & Williams, Colorectal Dis 2002

0

2

4

6

8

10

12

14

Pre-operative Post-operative

Normal

Incontinent flatus

Incontinent liquid

NU

MB

ER

Outcome of Anal Fistula SurgeryContinence - Questionnaire survey

Loose Seton 16/23 (70%)

75%

13%

25%

50%

19%

38%

12

2

4

8

3

6

Wolverhampton Data, Joy & Williams, Colorectal Dis 2002

0

1

2

3

4

5

6

7

8

9

10

Pre-operative Post-operative

NU

MB

ER

Outcome of Anal Fistula SurgeryContinence - Questionnaire survey

Cutting Seton 10/17 (59%)

90%

10%

50%50%

20%

30%

Normal

Incontinent flatus

Incontinent liquid

Incontinent solid9

1

5 5

32

Wolverhampton Data, Joy & Williams, Colorectal Dis 2002

• Fistulotomy mainstay of treatment for low and simple fistulas

• Setons useful in treatment of high and complex fistulas

• Other surgical techniques may need to be employed in complex fistulas

• Never do too much at one go

Fistulotomy and SetonsConclusions