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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. Anal Fistula Surgery Results of Fistulotomy.

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fistulotomy and setons
Fistulotomy and Setons

Mr Graham Williams

Consultant Colorectal Surgeon

Royal Wolverhampton Hospitals NHS Trust

anal fistula
Anal Fistula
  • Eradicate fistula
  • Maintain continence

Aims of Surgical Treatment

slide5

Anal Fistula SurgeryProblems Following Fistulotomy

  • Extensive wound & delayed healing
  • Gutter / key hole deformity
  • Anal incontinence
    • Flatus (10% - 20%)
    • Soiling (5% - 10%)
    • Urgency
    • Faecal incontinence
slide7

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)
slide8

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 surgery results of loose seton
Anal Fistula SurgeryResults of Loose Seton

Thomson & Ross Int J Colorect Dis 1989

  • 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
loose seton long term results
Loose SetonLong term Results

Total

Free of Sepsis

20

20

Number of Patients

13

4

6 months

>10 years

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

seton fistulotomy cutting v two stage
Seton FistulotomyCutting v Two Stage

Garcia-Aguilar et al 1998. BJS

outcome of anal fistula surgery results clinical review
Outcome of Anal Fistula SurgeryResults - Clinical Review

Fistula Healing

Total

96%

Healed

17

NUMBER

75%

12

Loose seton

Cutting seton

Wolverhampton Data, Joy & Williams, Colorectal Dis 2002

outcome of anal fistula surgery results clinical review14

Total

“Full Control”

Outcome of Anal Fistula SurgeryResults - Clinical Review

Continence

91%

23

NUMBER

94%

17

Loose seton

Cutting seton

Wolverhampton Data, Joy & Williams, Colorectal Dis 2002

outcome of anal fistula surgery continence questionnaire survey
Outcome of Anal Fistula SurgeryContinence - Questionnaire survey

Normal

Loose Seton 16/23 (70%)

Incontinent flatus

75%

Incontinent liquid

NUMBER

12

50%

38%

8

25%

19%

6

13%

4

3

2

Pre-operative

Post-operative

Wolverhampton Data, Joy & Williams, Colorectal Dis 2002

outcome of anal fistula surgery continence questionnaire survey16

Normal

Incontinent flatus

Incontinent liquid

Incontinent solid

Outcome of Anal Fistula SurgeryContinence - Questionnaire survey

Cutting Seton 10/17 (59%)

90%

9

NUMBER

50%

50%

30%

5

5

20%

10%

3

2

1

Pre-operative

Post-operative

Wolverhampton Data, Joy & Williams, Colorectal Dis 2002

slide17

Fistulotomy and SetonsConclusions

  • 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