Journal of Gastrointestinal Surgery

, Volume 13, Issue 6, pp 1116–1119 | Cite as

The Use of the Loose Seton Technique as a Definitive Treatment for Recurrent and Persistent High Trans-Sphincteric Anal Fistulas: A Long-Term Outcome

  • Arieh Eitan
  • Marina Koliada
  • Amitai BickelEmail author
Original Article



The loose seton technique (suggested to avoid any external anal division following seton placement, to ensure anal continence) was assessed as the ultimate approach for primary as well as recurrent and persistent anal fistula.

Study Design

Between 2000 and 2006, 97 patients were operated for trans-sphincteric anal fistula, 41 patients of whom (42.3%) underwent the loose seton technique. The outcome was assessed periodically at the outpatient colorectal clinic and finally by detailed telephonic questionnaire. Mean age was 45.3 years. Thirty one operations were elective (75.6%). Fifteen (36.5%) patients had concomitant diseases, of whom three suffered from Crohn’s disease. Twenty nine patients had previous anal operations.


The time from seton placement to its removal ranged from 3 to 7 months. At short-term follow-up, early complications were noted in five patients (bleeding in one and abscess formation in four). Late complications included liquid stool soiling in one patient (2.4%), solid soiling in two, and mucous discharge in three. Post-operative clinical assessment of incontinence according to Cleveland Clinic Incontinence Score revealed scoring ranging from 2 to 6 in those six patients. Neither gross stool nor flatus incontinence was noted. Fistula recurrence (persistence) was noted in eight (19.5%) patients and successfully treated by the same loose seton technique.


The loose seton technique for trans-sphincteric anal fistula carries favorable results and can be safely applied while preserving the external sphincter function. We also recommend repeating the technique in case of post-operative fistula recurrence or persistence.


Perianal fistula Loose seton technique Anal incontinence 


  1. 1.
    Phillips RKS, Lunniss PJ. Anorectal sepsis. In Nicholls RJ, Dozois RR, eds. Surgery of the colon & rectum. New York: Churchill Livingstone, 1997, pp 255–284.Google Scholar
  2. 2.
    Scott NA, Keighley M. Anorectal fistula. In: Keighley MRB, Wiliams NS ed. Surgery of the anus, rectum and colon. W.B. Saunders, 1999, pp. 488–530.Google Scholar
  3. 3.
    van Tets WF, Kuijpers HC. Continence after anal fistulotomy. Dis Colon Rectum 1994;37:1194–1197.PubMedCrossRefGoogle Scholar
  4. 4.
    McCourtney JS, Finlay IG. Setons in the surgical management of fistula in ano. Br J Surg 1995;82:448–452.PubMedCrossRefGoogle Scholar
  5. 5.
    Williams JG, MacLeod CA, Rothenberger DA, Goldberg SM. Seton treatment of high anal fistulae. Br J Surg 1991;78:1159–1161.PubMedCrossRefGoogle Scholar
  6. 6.
    Kuypers HC. Use of seton in the extrasphincteric anal fistula. Dis Colon Rectum 1984;27:109–110.PubMedCrossRefGoogle Scholar
  7. 7.
    Takesue Y, Ohge H, Yokohama T, Murakami Y, Imamura Y, Sueda T. Long term results of seton drainage on complex anal fistulae in patients with Crohn’s disease. J Gastroenterol 2002;37:912–915.PubMedCrossRefGoogle Scholar
  8. 8.
    Theerapol A, So BYJ, Ngoi SS. Routine use of setons for the treatment of anal fistulae. Singapore Med J 2002;43:305–307.PubMedGoogle Scholar
  9. 9.
    Durgun V, Perek A, Kapan M, Kapan S, Perek S. Partial fistulotomy and modified cutting seton procedure in the treatment of high extrasphincteric perianal fistulae. Dig Surg 2002;19:56–58.PubMedCrossRefGoogle Scholar
  10. 10.
    Buchanan GN, Owen HA, Torkington J, Lunniss PJ, Nicholls RJ, Cohen CRG. Long term outcome following loose-seton technique for external sphincter preservation in complex anal fistula. Br J Surg 2004;91:476–480.PubMedCrossRefGoogle Scholar
  11. 11.
    Kennedy HL, Zegarra JP. Fistulotomy without external sphincter division for high anal fistulae. Br J Surg 1990;77:898–901.PubMedCrossRefGoogle Scholar
  12. 12.
    Thomson JPS, Ross AHM. Can the external anal sphincter be preserved in the treatment of trans-sphincteric fistula-in-ano. Int J Colorect Dis 1989;4:247–250.CrossRefGoogle Scholar
  13. 13.
    Lunniss PJ, Thomson JPS. The loose seton. In Phillips RKS, Lunniss PJ, eds. Anal fistula: surgical evaluation and management. London: Chapman and Hall Medical, 1996, pp 87–93.Google Scholar
  14. 14.
    Jorge JMN, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993;36:77.PubMedCrossRefGoogle Scholar
  15. 15.
    Hammond TM, Knowles CH, Porrett T, Lunniss PJ. The snug Seton; short and medium term results of slow fistulotomy for idiopathic anal fistula. Colorectal Dis 2006;8:328–337.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2009

Authors and Affiliations

  1. 1.Department of SurgeryWestern Galilee Hospital, Nahariya, affiliated to the Faculty of Medicine, the Technion, Israel Institute of TechnologyHaifaIsrael
  2. 2.Department of SurgeryWestern Galilee HospitalNahariyaIsrael

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