Tube Loop (Seton) Drainage Treatment ofRecurrent Extrasphincteric Perianal Fistulae

Gabor Balogh, MD, PhD, Kaposvar, Hungary

Tube loop seton drainage treatment of multiplyrecurring high-spreading extrasphincteric peri-anal fistulae in 19 patients is reported in thisstudy. The drainage loop setons make possiblethe rinsing of the wound following fistulectomyand also the bidirectional drainage of the wounddischarge. Strangulation of the wound and anearly closure of the fistula and hence the devel-opment of recurrence is prevented by means ofcontrolled formation of scarred tissue. Thesphincteral musculature of the anus is also pro-tected from damage. Thirty-five recurring fistulaeof 19 patients included in the present study weretreated successfully by this method. Two fistularecurred. None of these patients developed in-continence. The use of tube loop setons wasfound to have advantages over the pull-outmethod in cases of high-spreading multiply re-curring extrasphincteric or suprasphincteric peri-anal fistulae. Am J Surg. 1999;177:147–149.© 1999 by Excerpta Medica, Inc.

Perianal fistulae were first classified and the main prin-ciples of their surgical treatment described by SirAlan Parks.23 An essential and still influential con-

tribution to the subject was made by Girona et al8 andAthanasiadis et al.2,3 Ritter26 has also given a valuabledescription of the phenomenon. Perianal fistulae are fre-quently difficult to treat and eliminate. In Crohn’s dis-ease2,15 and also in special cases the rate of recurrence ishigher; in diabetes and conditions involving immunodefi-ciency the fistula often persists. In the majority of casesvarious surgical methods can be effective if they are se-lected according to the types of the fistulae. However, in2% to 9% of the cases,3,5,10,18,19,29 recurrence occurred.These data apply to all types of fistulae classified by Parks.The prevalence of extrasphincteric or suprasphinctericperianal fistulae has been reported to range between 1.3%and 17.0%.3,5,12,16,19,26,28 In cases of multiply recurringhigh-spreading extrasphincteric fistulae, the elimination ofpus formation is a most difficult task for the surgeon, sincehealing has to be achieved in a site deformed by scars dueto several previous surgical interventions.

PATIENTSNineteen patients with recurring high-spreading extra-

sphincteric perianal fistulae were treated at our departmentbetween January 1, 1988 and December 31, 1997. Loop(seton) drainage was applied in 16 males and 3 females, theyoungest patient being 26 and the oldest 67, their averageage being 50.9 years. The patients’ history dated back to5 years as an average (1 to 12 years). The average numberof previously performed operations was 4 (2 to 9), thenumber of fistulae in the 19 patients amounted to 35, andthe number of drainage loop setons used was 35. Six of thepatients had three fistulae each. In these patients, surgerywas performed in two stages. In 6 cases in addition to theexisting recurrent fistulae, abscess formation was also ob-served, however, not in another site but as an acute com-plication of the existing fistulae. The underlying diseasewas nonspecific perianal infection in 14 cases, Crohn’sdisease in 3 cases, and tuberculosis in 2 cases.

In none of the patients were used more than two drainageloop setons at the same time. The average duration ofhospital treatment amounted to 7.2 days, whereas in thecase of the patients treated in two stages this period wasroughly twice as long. Two of the recurrences occurred inthe 19 patients with 35 fistulae treated with drainage loopsetons. The last patient having received drainage loopsetons has been free of complaints for 1.5 years. No incon-tinence, temporary or permanent, occurred. These patientshad been treated in other institutions, the majority havingbeen admitted to different departments. The surgery wasalso carried out by different surgeons. Oncotomy, tampon-ade, and Pennington surgery had been carried out in eachpatient in the course of previous surgical interventions.24

METHODThe patient is placed on the operating table in the

lithotomy position. Following Recamier dilatation, an ano-scope is inserted into the anus. Through the perianal orificeof the fistula a bulbous probe is inserted, whose appearencein the lumen is monitored through the anascope. Next, afistulectomy is carried out proceeding from the wide expo-sure, from the direction of the perianal skin toward theinner opening of the fistula. After rinsing the passage andthe wound, a drain is inserted. A loop made of Nelatoncatheter of 16-18Ch was found to be the most appropriate,causing the least discomfort to the patients (Figure).

One of the branches of the rubber tube is brought outthrough the anal canal while the other one is led outthrough the passage formed after the removal of the fistula.The two branches of the drain are stitched together andtightly knotted so that each lumen is closed. Thus, a tubeloop drainage is formed on which one or two side openingsare made. The operation is finished after bleeding has beencontrolled and tamponade placed.

From the Second Department of Surgery and Thoracic Surgery,Kaposi Mor County Hospital, Kaposvar, Hungary.

Requests for reprints should be addressed to Gabor Balogh,MD, PhD, Kaposi Mor County Hospital, Second Department ofSurgery and Thoracic Surgery, Kaposvar, Tallian Gy. Street 20–34, 7400 Hungary.

Manuscript submitted April 8, 1998, and accepted in revisedform November 18, 1998.

© 1999 by Excerpta Medica, Inc. 0002-9610/99/$–see front matter 147All rights reserved. PII S0002-9610(98)00322-5

After defecation and also on one or two further occasions,the wound is rinsed through the branches of the tube loopdrainage inserted. The rinsing solution is injected into thedrain by pricking its branches (Figure). While the rinsingsolution is being injected, both the anal canal and the scarfrom fistulectomy are rinsed by way of changing the positionof the side opening of the loop. Depending on the characterof the wound discharge, physiological saline or 3% hydroper-oxide are used and occasionally, in cases of thick fibropu-rulent pus, an antiseptic solution of antibiotics is applied.

The primary aim of the rinsing treatment is the mechan-ical cleansing of the wound, wound toilet after passingmotions, and also the removal of the rejected tissue frag-ments as well as the reduction of the number of pathogens.

After 7 to 10 days the drains are removed provided thereare no signs of tissue inflammation, the amount of thedischarge has decreased, and on the surface in contact withthe tube loop drainage granulation has started. Daily anti-septic baths and sterile dressing are applied to the perinealwound until it heals.

Advantages of the method are as follows: There is aminimal need for instruments; it can be carried out quickly,posing minimal operational burden on the patient; thesphincter musculature of the anus is not damaged, so noincontinence is caused; it prevents the strangulation of thepassage of the fistula; a two-way drainage is created for thewound discharge; rinsing of the wound is rendered possible,thus promoting both mechanical and chemical rinsing; andtamponade is necessary only for a few days. Disadvantagesof the method are that the patient needs to be treated

several times a day; as the first few treatments are painful,intolerant patients may require epidural anesthesia; andwearing the tube loop drainage in uncomfortable.

COMMENTSThe history of perianal fistulae dates back to the times of

Hippocrates. It is known from the history of medicine byGarrison7 that this topic was touched upon by John ofArdennes as early as 1376. Louis the XIV was successfullytreated for this condition by Royal Surgeon Felix in themiddle of the 18th century. The anatomy of musculature inthe pelvic region was first described by German and Frenchanatomists in the middle of the 19th century. The surgicalanatomy of perianal fistulae was founded in terms of inter-nal and external sphincters as well as the puborectal mus-culature by Milligan and Morgan20 in 1934. The anatomyof the ducts of the anal glands playing a key role in theformation and pathomechanism of fistulae was first decribedby Chiary in 1878.23 Further progress in the subject was madeby Eisenhammer,6 Goliger,9 Lilius,13 and Stelzner.27 Themodern surgical principles were established by Parks.22

The surgical management of high-spreading extrasphinc-teric fistulae has been of two types: closing or leaving openthe internal opening of the fistula. Lange (cit3) in 1886closed the internal opening following fistulectomy. In spiteof its unquestionable advantage, the method had notspread widely. The “T” method was first suggested bySalamon in 1896 (cit1). This procedure involves the exci-sion and treatment of the fistula open. This method hashad several followers.13,14,18,20,28 Besides the various pull-out methods (thread, metallic wire, rubber band, and soforth)10,12,14,25,27 various other surgical methods of one ortwo stages are also described.2,16,17,28,30

The guiding principle of the surgical elimination of perianalfistulae is complete removal of the fistular passage on the onehand, and the sparing of the sphincteric musculature of theanus, ie, the avoidance of incontinence, on the other. Fur-thermore, that operation technique should be applied thathelps avoid recurrences. In the present paper, data on patientshaving had several recurrences of their fistulae classified astype III in the Parks’ classification23 are presented. Followingmultiple fistulectomy, the perianal tissues underwent defor-mation due to scarring. The majority of patients developedtwo or more fistulae. With use of the various pull-out meth-ods, the foreign material pulled out induces scarring while italso contributes to the healing of the site of the excised fistula.The thread knotted every 4 to 5 days cuts through themuscular fibers of the sphincters, causing scarring, which canlead to malfunctions, ie, incontinence. Consequently, a solu-tion that causes appropriate scarring without damaging thefibers of the sphincters, gives better functional results, and alsoeliminates causes leading to recurrences should be applied.

In our experience, the recurrences of perianal fistulae couldbe avoided bearing the following principles in mind: (1) nearlytotal excision of the fistular passage; (2) creating a two-waytube loop drainage, so that the perianal wound can be cleanedcontinuously; (3) preventing reinfection associated with def-ecation by means of lavage; and (4) eliminating early closureof the fistula or strangulation caused by scarring due to theinsertion of the tube loop drainage—“controlled” formationof scar tissue.

These treatment objectives can be achieved by means of a

Figure 1. Tube loop drainage treatment.

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148 THE AMERICAN JOURNAL OF SURGERY® VOLUME 177 FEBRUARY 1999

thorough fistulectomy and tube loop drainage. The basic ideaof its application comes from the fact that in all areas ofsurgery various drains are used in the aspiration and drainageof cavities. For the elimination of suppuration in the thoraxand abdomen, various drain tubes are used for several weeks inmany cases. After the removal of these drain tubes, thethoracic or abdominal wall closes spontaneously. It is rare forthe scarred passage forming around the drain tube to remainopen for a long time. Around the tube left in the wound for8 to 10 days, scar tissue forms. Thus, it is not the wall of azigzagged wound that gets scarred but that of a regular cylin-drical arching cavity of the same diameter everywhere. In ourexperience, after the removal of the loop drain the lumen ofthe passage created by the tube closes and heals. In no caseshave we found feculent discharge for more than 3 days.Ritter26 claims that the postoperative treatment of the woundcavity is a disputable area of fistula surgery, as tamponade isconsidered to be necessary while a continuous strip drain maydisturb continence. When loop drainage is applied, no tam-ponade is necessary or it is necessary only for a few days. In thecase of marsupialization loop drainage tamponade is unneces-sary, as early closure or strangulation is prevented by therubber tube inserted. The excision of perianal skin and sub-cutaneous fat need not be performed on such a big area asin the case of marsupialization. This also reduces the degreeof postoperative scarring. As a result of this, the perisphinc-teric region heals with a lesser degree of deformation.

Following the surgical treatment of perianal fistulae, thedevelopment of recurrences are inevitable. In cases of mul-tiple recurrences, procedures and methods applied so farhave not been successful. The appropriateness of opera-tions performed previously is not evaluated here. For somepatients, previously performed fistulectomy, tamponade, orone of the various pull-out methods had not been success-ful. Therefore, to eliminate their conditions necessitatedsolutions other than the ones mentioned previously.

With the technique of pulling out rubber bands propagatedby Hungarian authors,12,24 the muscle fibers of the sphinctersare affected to the same extent as with the use of “seton”techniques. Loop drainage spares the anal sphincters. This ismost important, as the techniques applied previously have notbeen successful in any of the patients included in the presentstudy. The lavage pumped into the fistula through the open-ings on the side of the drain-loop makes permanent cleaningand disinfection possible. Moreover, lavage prevents rein-fection resulting from defecation, which is one of the mostfrequent causes of the recurrence of the fistula.

The data presented in the present paper allow for theconclusion that in the elimination of high-spreading mul-tiply-recurring extrasphincteric or suprasphincteric peri-anal fistulae, the application of tube loop drainage tech-nique proved to be more effective than the various pull-outmethods. The guided scarring and the permanent clearingcan explain the success of the present method. The appli-cation of this procedure seems to offer a new alternative inthe successful surgical treatment of perianal fistulae.

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