Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

The cutting seton

An experience at King Faisal Specialist Hospital

  • 68 Accesses

  • 18 Citations


PURPOSE: A 30-percent gas incontinence rate has been reported after the use of the cutting seton in complex anal fistulas. This study was undertaken to determine the morbidity and efficacy of the cutting seton in the management of complex anal fistulas at the King Faisal Specialist Hospital. METHODS: All patients who had a cutting seton inserted in the colorectal unit at King Faisal Specialist Hospital between 1990 and 1998 were identified from a colorectal data base. The charts of these patients were examined and form the basis of this report. Setons were inserted and tied under general anesthesia after the fistula tract had been identified. All fistulas were transsphincteric, and if it seemed that more than 30 percent of the internal sphincter would need to be divided to “lay open” the tract, a seton was used. Fistulas were designated “high” if the internal opening was above the level of the anal crypts. Setons were tightened under general anesthesia at intervals of three to four weeks until cutting was complete. Patients were followed up until wounds had healed and fistula symptoms had resolved. RESULTS: Data from 47 patients were analyzed. The mean duration of disease before surgery was 39.1 months. Twenty-five patients had had previous anorectal abscess drainage. The mean number of previous fistula operations was 2.2. Before seton insertion five patients were incontinent to gas, two to liquid stool, and none to solid stool. Continence status before seton surgery was unknown in 11 patients. There were 16 “high” fistulas. Methylene blue dye was used to identify the internal opening in 14 patients when simple probing failed. Setons were tightened on three or more occasions in 12 patients, twice in 19 patients, and once in 16 patients. Mean perineal wound healing time was six months. The mean length of follow-up was 1.1 years, and during this time one fistula recurred. After treatment a total of 17 patients (36.2 percent) were incontinent to gas, 4 to liquid feces (8.5 percent), and 1 to solid feces (2.3 percent). Four patients complained of soiling. Of previously continent patients, 9.5 percent were significantly incontinent to gas, but in addition 21.4 percent were “occasionally” incontinent for gas. CONCLUSION: The use of the cutting seton resulted in a significant gas incontinence rate of 9.5 percent after a mean follow-up of 1.1 years. Only 1 fistula recurred.

This is a preview of subscription content, log in to check access.


  1. 1.

    McCourtney JS, Finlay IG. Setons in the surgical management of fistula in ano. Br J Surg 1995;82:448–52.

  2. 2.

    Hanley PH. Rubber band seton in the management of abscess-anal fistula. Ann Surg 1978;187:435–7.

  3. 3.

    Culp CE. Use of Penrose drains to treat certain anal fistulas: a primary operative seton. Mayo Clin Proc 1984;59:613–7.

  4. 4.

    Thompson JE, Bennion RS, Hilliard G. Adjustable seton in the management of complex anal fistula. Surg Gynecol Obstet 1989;169:551–2.

  5. 5.

    Cirocco WC, Rusin LC. Simplified seton management for complex anal fistulas: a novel use for the rubber band ligator. Dis Colon Rectum 1991;34:1135–7.

  6. 6.

    Loberman Z, Har-Shai Y, Schein M, Hashmonai M. Hangman's tie simplifies seton management of anal fistula. Surg Gynecol Obstet 1993;177:413–4.

  7. 7.

    Van Tets WF, Kuijpers JH. Seton treatment of perianal fistula with high anal or rectal opening. Br J Surg 1995;82:895–7.

  8. 8.

    Walfisch S, Menachem Y, Koretz M. Double seton—a new modified approach to high transsphincteric anal fistula. Dis Colon Rectum 1997;40:731–2.

  9. 9.

    Balogh G. Tube loop (seton) drainage treatment of recurrent extrasphincteric perianal fistulae. Am J Surg 1999;177:147–9.

  10. 10.

    Hamalainen KP, Sainio AP. Cutting seton for anal fistulas: high risk of minor control defects. Dis Colon Rectum 1997;40:1443–7.

  11. 11.

    Williams JG, MacLeod CA, Rothenberger DA, Goldberg SM. Seton treatment of high anal fistulae. Br J Surg 1991;78:1159–61.

  12. 12.

    Christensen A, Nilas L, Christiansen J. Treatment of transsphincteric anal fistulas by the seton technique. Dis Colon Rectum 1986;29:454–5.

  13. 13.

    Tocchi A, Mazzoni G, Lepre L, Costa G, Liotta G, Maggiolini F. Recurrent high anal fistula: treatment with the use of seton [in Italian]. G Chir 1997;18:375–7.

  14. 14.

    Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993;36:77–97.

  15. 15.

    Pearl RK, Andrews JR, Orsay CP,et al. Role of the seton in the management of anorectal fistulas [author reply]. Dis Colon Rectum 1993;36:578–9.

  16. 16.

    Lilius HG. Fistula in ano: an investigation of human foetal anal ducts and intramuscular glands and a clinical study of 150 patients. Acta Chir Scand 1968;383(Suppl):1–88.

  17. 17.

    Parks AG, Stitz RW. The treatment of high fistula-in-ano. Dis Colon Rectum 1976;19:487–99.

  18. 18.

    McCourtney JS, Finlay IG. Cutting seton without preliminary internal sphincterotomy in management of complex high fistula-in-ano. Dis Colon Rectum 1996;39:55–8.

  19. 19.

    Pearl RK, Andrews JR, Orsay CP,et al. Role of the seton in the management of anorectal fistulas [editorial comment]. Dis Colon Rectum 1993;36:577–8.

  20. 20.

    Lunniss PJ, Kamm MA, Phillips RK. Factors affecting continence after surgery for anal fistula. Br J Surg 1994;81:1382–5.

  21. 21.

    Belliveau P, Thomson JP, Parks AG. Fistula-in-ano. A manometric study. Dis Colon Rectum 1983;26:152–4.

  22. 22.

    Pescatori M, Maria G, Anastasio G, Rinallo L. Anal manometry improves the outcome of surgery for fistula-in-ano. Dis Colon Rectum 1989;32:588–92.

  23. 23.

    Garcia-Aguilar J, Belmonte C, Wong DW, Goldberg SM, Madoff RD. Anal fistula surgery. Factors associated with recurrence and incontinence. Dis Colon Rectum 1996;39:723–9.

  24. 24.

    Fasth SB, Nordgren S, Hultén L. Clinical course and management of suprasphincteric and extrasphincteric fistula-in-ano. Acta Chir Scand 1990;156:397–402.

  25. 25.

    Graf W, Påhlman L, Ejerblad S. Functional results after seton treatment of high transsphincteric anal fistulas. Eur J Surg 1995;161:289–91.

  26. 26.

    Garcia-Aguilar J, Belmonte C, Wong DW, Goldberg SM, Madoff RD. Cutting seton versus two-stage seton fistulotomy in the surgical management of high anal fistula. Br J Surg 1998;85:243–5.

  27. 27.

    Isbister WH. Fistula-in-ano. Aust N Z J Surg, 1999;69:768–9.

  28. 28.

    Cirocco WC, Reilly JC. Challenging the predictive accuracy of Goodsall's rule for anal fistulas. Dis Colon Rectum 1992;35:537–42.

  29. 29.

    Bassan MM, Dudai M, Shalen O. Near-fatal systemic oxygen embolism due to wound irrigation with hydrogen peroxide. Postgrad Med J 1982;58:448–50.

  30. 30.

    Gerrish SP. Gas embolism due to hydrogen peroxide. Anaesthesia 1985;40:1244.

Download references

Author information

Correspondence to Dr. William H. Isbister M.D., Ch.B..

About this article

Cite this article

Isbister, W.H., Al Sanea, N. The cutting seton. Dis Colon Rectum 44, 722–727 (2001).

Download citation

Key words

  • Fistula-in-ano
  • Cutting seton