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
Recommended
