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Fistulotomy and Setons

Fistulotomy and Setons. Mr Graham Williams Consultant Colorectal Surgeon Royal Wolverhampton Hospitals NHS Trust. Surgical Treatment of Anal Fistulas. Anal Fistula. Eradicate fistula Maintain continence. Aims of Surgical Treatment. Anal Fistula Surgery Results of Fistulotomy.

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Fistulotomy and Setons

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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

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