Dr.Alaa AL-wadees, the lecturer at the department of surgery, has published a research in an American Journal entitled "Using Thick Loose Seton Reduces the Incontinence and Enhances Healing Rate of High Type Fistula in Ano, a Retrospective Study&quo


"Using Thick Loose Seton Reduces the Incontinence and Enhances Healing Rate of High Type Fistula in Ano, a Retrospective Study"



Journal of Surgery 2016; 4(4): 85-88 http://www.sciencepublishinggroup.com/j/js 





     The recurrence of fistula in ano after operation is distressing for the patients. The aim of this study is to minimize the recurrence of fistula in ano after surgery and to protect from postoperative incontinence. 126 patients were presented to the clinic as a primary or a recurrent high fistula in ano. Only two cases of them were emergency. Fistulas due to malignancy, inflammatory bowel disease or tuberculosis were excluded. Thick loose silk suture was applied for 6 months. Healing rate was 91.26% after first operation, and 82% after second operation. No reported incontince. Application of thick seton is associated with low recurrence rate and no fecal incontinence.






    The most common cause of fistula in ano FIA is the infection of the crypto-glandular tissue with resultant abscess formation. The abscess represents acute inflammation and fistula is the chronic process [1-4]. Other causes include inflammatory bowel disease (mainly Cohn’s disease), malignancy and tuberculosis [5]. Most of high type FIA and subsequent incontinence are iatrogenic and can be avoided by careful surgery [6]. Parks et al classified FIA into intersphincteric, trans-sphincteric, supra- sphincteric and extra- sphincteric which is the most widely used and taught classification [7]. Treatment of FIA remains a challenge. However, surgical treatment of drainage, removing fistula tract, preventing recurrence and sparing anal sphincter remains the method of choice [8]. Several types of operations are developed to achieve these goals. Fistulotomy (lay open technique) has high recurrence rate (9%) with 33% incontinence rate [9-14]. Advancement flap technique (AFT) may be considered if fistulotomy cannot be done. Success rate of AFT is about 64%-95% but this figure decreases with subsequent attempts, however, better outcome could be obtained when AFT is combined with application of fibrin glue [15-17]. Flatus and fecal incontinence rate with AFT still relatively high (about 9-12% for fecal incontinence and 38% for flatus incontinence) [18]. Many reports showed no advantage of fibrin glue over fistulotomy. Success rates were about 14-85% [19-22].







  Patients and Methods:  


      This is a retrospective study of 126 patients of FIA managed at our tertiary coloproctology centre through January 2012 to February 2015, including primary and recurrent types. Patients with FIA due to inflammatory bowel disease or malignancy were excluded. Perianal and/or rectal ultrasonography and Magnetic Resonance Imaging were done for all cases. All operations were performed as day cases by a single consultant surgeon. Spinal anesthesia was used and excision of the subcutaneous tract was performed. A thick (No. 2 silk, double suture) is applied with a loose knot through the tract and is left for 6 months. Spontaneous extrusion of the suture is reported at 5-6 months. A second operation is planned to cut the remnant of the tract, if the seton still fixed after 6 months. In all cases, the sphincter complex remained intact. The postoperative care includes discharge in the same day. Patients are seen every two weeks then every month. Metronidazole 250mg, 8 hourly is givenfor all patients; in addition to local wash with normal saline and antiseptic soap.


   Patient demographic characteristics: the majority of patients were men (94% male and 6% female). 36% of patients were between 30-40 years old while 25% were between 20-30 years old and 21% were between 40-50 years old. (see table 1).

 Mode of presentation: eighty patients (63.4%) were presented for the first time to the surgical clinic while 18 patients (14.3%) were presented with perianal abscess which was drained initially and then the patients were scheduled for elective FIA surgery. 28 patients (22.2%) had recurrent FIA. (see table 1)

 Anatomical types of FIA included in this study: All cases were high type FIA with 63% of cases were inter-sphincteric, 26% were supra-sphincteric and 12% were trans-sphincteric. (see figure 1).

 Outcome after first operation: total number of patients was 126. Those who had complete healing after 6 months were 115 patients (91.26%) and those who had recurrence and failure of first operation were 11 patients (8.73%). 

Outcome after second operation: nine patients with recurrence had second operation for removal of the seton and excision of the fistula. Seven patients had complete healing (82%) and 2 patients needed more sophisticated approach (18%).