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  1. Fistulotomy and Setons Mr Graham Williams Consultant Colorectal Surgeon Royal Wolverhampton Hospitals NHS Trust

  2. Surgical Treatment of Anal Fistulas

  3. Anal Fistula • Eradicate fistula • Maintain continence Aims of Surgical Treatment

  4. Anal Fistula SurgeryResults of Fistulotomy

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

  6. Anal Fistula SurgeryWhen is it Safe to Lay Open D C A B

  7. 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)

  8. 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)

  9. 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

  10. 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

  11. Anal Fistula SurgeryResults of Cutting Seton

  12. Seton FistulotomyCutting v Two Stage Garcia-Aguilar et al 1998. BJS

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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