Fistulotomy or seton in anal fistula: a decisional algorithm


Fistula in ano is a common proctological disease. Several authors stated that internal and external anal sphincters preservation is in the interest of continence maintenance. The aim of the present study is to report our experience using a decisional algorithm on sphincter saving procedures that achieved us to obtain good results with low rate of complications. From 2008 to 2011, 206 patients underwent surgical treatment for anal fistula; 28 patients underwent perianal abscess drainage plus seton placement of trans-sphincteric or supra-sphincteric fistula (13.6 %), 41 patients underwent fistulotomy for submucosal or low inter-sphincteric or low trans-sphincteric anal fistula (19.9 %) and 137 patients underwent partial fistulectomy or partial fistulotomy (from cutaneous plan to external sphincter muscle plan) and cutting seton placement without internal sphincterotomy for trans-sphincteric anal fistula (66.50 %). Healing rates have been of 100 % and healing times ranged from 1 to 6 months in 97 % of patients treated by setons. Transient fecal soiling was reported by 19 patients affected by trans-sphincteric fistula (11.5 %) for 4–6 months and then disappeared or evolved in a milder form of flatus occasional incontinence. No major incontinence has been reported also after fistulotomy. Fistula recurred in five cases of trans-sphincteric fistula treated by seton placement (one with abscess) (1/28) (3.5 %) and four with trans-sphincteric fistula (4/137) (3 %). Our algorithm permitted us to reduce to 20 % sphincter cutting procedures without reporting postoperative major anal incontinence; it seems to open an interesting way in the treatment of anal fistula.

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  1. 1.

    Zanotti C, Martinez-Puente C, Pascual I, Pascual M, Herreros D, García-Olmo D (2007) An assessment of the incidence of fistula-in-ano in four countries of the European Union. Int J Colorectal Dis 22:1459–1462

    PubMed  Article  Google Scholar 

  2. 2.

    Nelson R (2002) Anorectal abscess fistula: what do we know? Surg Clin North Am 82:1139–1151 v–vi

    PubMed  Article  Google Scholar 

  3. 3.

    Sainio P (1984) Fistula-in-ano in a defined population. Incidence and epidemiological aspects. Ann Chir Gynaecol 73:219–224

    PubMed  CAS  Google Scholar 

  4. 4.

    Ramanujam PS, Prasad ML, Abcarian H, Tan AB (1984) Perianal abscesses and fistulas. A study of 1023 patients. Dis Colon Rectum 27(9):593–597

    PubMed  Article  CAS  Google Scholar 

  5. 5.

    Scoma JA, Salvati EP, Rubin RJ (1974) Incidence of fistulas subsequent to anal abscesses. Dis Colon Rectum 17(3):357–359

    PubMed  Article  CAS  Google Scholar 

  6. 6.

    Vasilevsky CA, Gordon PH (1984) The incidence of recurrent abscesses or fistula-in-ano following anorectal suppuration. Dis Colon Rectum 27(2):126–130

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    Oliver I, Lavueva FJ, Piorez VF et al (2003) Randomized clinical trial comparing simple drainage of anorectal abscess with and without fistula tract treatment. Int J Colorectal Dis 18(2):107–110

    PubMed  CAS  Google Scholar 

  8. 8.

    Blumetti J, Abcarian A, Quinteros F, Chaudhry V, Prasad L, Abcarian H (2012) Evolution of treatment of fistula in ano. World J Surg 36:2162–2167

    Article  Google Scholar 

  9. 9.

    Zbar AP, Khikin M (2012) Should we care about the internal anal sphincter? Dis Colon Rectum 55:105–108

    PubMed  Article  Google Scholar 

  10. 10.

    Zbar AP, Ramesh J, Beer-Gabel M, Salazar R, Pescatori M (2003) Conventional cutting vs internal anal sphincter-preserving seton for high trans-sphincteric fistula: a prospective randomized manometric and clinical trial. Tech Coloproctol 7:89–94

    PubMed  Article  CAS  Google Scholar 

  11. 11.

    Atkin GK, Martins J, Tozer P, Ranchod P, Phillips RKS (2011) For many high anal fistulas, lay open is still a good option. Tech Coloproctol 15:143–150

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    Cariati A, Piromalli E, Copello F, Torelli I (2012) Anal stretch for chronic anal fissure: an old operation that stood the test of time. Langenbecks Arch Surg. doi:10.1007/s00423-012-0969-x

    PubMed  Google Scholar 

  13. 13.

    Chuang-Wei C, Chang-Chieh W, Cheng-Wen H, Tsai-Yu L, Chun-Che F, Shu-Wen J (2008) Cutting seton for complex anal fistulas. Surgeon 3:185–188

    Article  Google Scholar 

  14. 14.

    McCourtney JS, Finlay IG (1996) Cutting seton without preliminary internal sphincterotomy in management of complex high fistula-in-ano. Dis Colon Rectum 39:55–58

    PubMed  Article  CAS  Google Scholar 

  15. 15.

    Vial M, Parés D, Pera M, Grande L (2010) Faecal incontinence after seton treatment for anal fistulae with and without surgical division of internal anal sphincter: a systematic review. Colorectal Dis 12:172–178

    PubMed  Article  CAS  Google Scholar 

  16. 16.

    García-Aguilar J, Belmonte C, Wong DW, Goldberg SM, Madoff RD (1998) Cutting seton versus two-stage seton fistulotomy in the surgical management of high anal fistula. Br J Surg 85:243–245

    PubMed  Article  Google Scholar 

  17. 17.

    Pearl RK, Andrews JR, Orsay CP et al (1997) Role of the seton in the management of anorectal fistulas. Dis Colon Rectum 36:573–579

    Article  Google Scholar 

  18. 18.

    Hämäläinen KJ, Sainio AP (1997) Cutting seton for anal fistulas: high risk of minor control defects. Dis Colon Rectum 40:1443–1446

    PubMed  Article  Google Scholar 

  19. 19.

    Christensen A, Nilas L, Christiansen J (1986) Treatment of trans-sphinteric anal fistula by the seton technique. Dis Colon Rectum 29:454–455

    PubMed  Article  CAS  Google Scholar 

  20. 20.

    Ritchie RD, Sackier JM, Hodde JP (2009) Incontinence rates after cutting seton treatment for anal fistula. Colorectal Dis 11:564–571

    PubMed  Article  CAS  Google Scholar 

  21. 21.

    Parks AG, Stitz RW (1976) The treatment of high fistula-in-ano. Dis Colon Rectum 19:487–499

    PubMed  Article  CAS  Google Scholar 

  22. 22.

    Van Tets WF, Kuijpers JH (1995) Seton treatment of perianal fistula with high anal or rectal opening. Br J Surg 82:895–897

    PubMed  Article  Google Scholar 

  23. 23.

    Lasheen AE (2004) Partial fistulectomy and fistular wall flap for the treatment of high perianal fistulas. Surg Today 34:977–980

    PubMed  Article  Google Scholar 

  24. 24.

    Jivapaisarnpong P (2009) Core out fistulectomy, anal sphincter reconstruction and primary repair of internal opening in the treatment of complex anal fistula. J Med Assoc Thai 92:638–642

    PubMed  Google Scholar 

  25. 25.

    Khafagy W, Omar W, El Nakeeb A, Fouda E, Yousef M, Farid M (2010) Treatment of anal fistulas by partial rectal wall advancement flap or mucosal advancement flap: a prospective randomized study. Int J Surg 8:321–325

    PubMed  Article  Google Scholar 

  26. 26.

    Malik AI, Nelson RL, Tou S. (2010) Incision and drainage of perianal abscess with or without treatment of anal fistula. Cochrane Database of systematic reviews 7:CD 006827. doi:10.1002/14651858.CD006827.pub2

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Correspondence to Andrea Cariati.

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Cariati, A. Fistulotomy or seton in anal fistula: a decisional algorithm. Updates Surg 65, 201–205 (2013).

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  • Anal fistulas
  • Cutting seton
  • Fistulotomy
  • Anal sphincters
  • Anal incontinence