Fistulotomy and Setons Mr Graham Williams Consultant Colorectal Surgeon Royal Wolverhampton...
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![Page 1: Fistulotomy and Setons Mr Graham Williams Consultant Colorectal Surgeon Royal Wolverhampton Hospitals NHS Trust.](https://reader035.fdocuments.in/reader035/viewer/2022062314/56649ea25503460f94ba61c1/html5/thumbnails/1.jpg)
Fistulotomy and Setons
Mr Graham Williams
Consultant Colorectal Surgeon
Royal Wolverhampton Hospitals NHS Trust
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Surgical Treatment of Anal Fistulas
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Anal Fistula
•Eradicate fistula
•Maintain continence
Aims of Surgical Treatment
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Author Date Number Recurrence
Hill 1967 626 6 (1%)
Ani & Solanke 1976 82 14 (17%)
Kuijpers 1982 51 2 (4%)
Gingold 1983 74 1 (1%)
Kronborg 1985 26 3 (11%)
Lilius 1986 150 8 (5.5%)
Shouler 1986 115 8 (7%)
Anal Fistula SurgeryResults of Fistulotomy
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Anal Fistula SurgeryProblems Following Fistulotomy
• Extensive wound & delayed healing• Gutter / key hole deformity• Anal incontinence
–Flatus (10% - 20%)–Soiling (5% - 10%)–Urgency–Faecal incontinence
![Page 6: Fistulotomy and Setons Mr Graham Williams Consultant Colorectal Surgeon Royal Wolverhampton Hospitals NHS Trust.](https://reader035.fdocuments.in/reader035/viewer/2022062314/56649ea25503460f94ba61c1/html5/thumbnails/6.jpg)
Anal Fistula SurgeryWhen is it Safe to Lay Open
A
DC
B
![Page 7: Fistulotomy and Setons Mr Graham Williams Consultant Colorectal Surgeon Royal Wolverhampton Hospitals NHS Trust.](https://reader035.fdocuments.in/reader035/viewer/2022062314/56649ea25503460f94ba61c1/html5/thumbnails/7.jpg)
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)
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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)
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Anal Fistula SurgeryResults of Loose Seton
• 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
Thomson & Ross Int J Colorect Dis 1989
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Loose SetonLong term Results
0
5
10
15
20
6 months >10 years
20
4
13
20
Total
Free of Sepsis
Num
ber
of P
atie
nts
Buchanan et al, St mark’s Hospital, BJS 2004
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Anal Fistula SurgeryResults of Cutting Seton
Author Healing %
Recurrence %
Incontinence %
Williams et al 100 0 45
Pearl et al 97 3 --
McCourtney & Finlay
96 4 --
Hamalainen et al
94 6 63
Garcia Aguillar et al
92 8 50
Dzihi et al 100 0 38
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Seton FistulotomyCutting v Two Stage
MinneapolisData
Cuttingn = 12
Two-Stagen = 47
Recurrence 1 (8%) 4 (8%)
Incontinence 8 (75%) 31 (66%)
Score (0-21) 4.9 4.2
Satisfied 11 (92%) 40 (85%)
Garcia-Aguilar et al 1998. BJS
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0
2
4
6
8
10
12
14
16
18Total
Healed
Loose seton Cutting seton
NU
MB
ER
Fistula Healing
Outcome of Anal Fistula SurgeryResults - Clinical Review
75%
96%
12
17
Wolverhampton Data, Joy & Williams, Colorectal Dis 2002
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0
5
10
15
20
25
Total
“Full Control”
Loose seton Cutting seton
NU
MB
ER
Continence
Outcome of Anal Fistula SurgeryResults - Clinical Review
91%
94%23
17
Wolverhampton Data, Joy & Williams, Colorectal Dis 2002
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0
2
4
6
8
10
12
14
Pre-operative Post-operative
Normal
Incontinent flatus
Incontinent liquid
NU
MB
ER
Outcome of Anal Fistula SurgeryContinence - Questionnaire survey
Loose Seton 16/23 (70%)
75%
13%
25%
50%
19%
38%
12
2
4
8
3
6
Wolverhampton Data, Joy & Williams, Colorectal Dis 2002
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0
1
2
3
4
5
6
7
8
9
10
Pre-operative Post-operative
NU
MB
ER
Outcome of Anal Fistula SurgeryContinence - Questionnaire survey
Cutting Seton 10/17 (59%)
90%
10%
50%50%
20%
30%
Normal
Incontinent flatus
Incontinent liquid
Incontinent solid9
1
5 5
32
Wolverhampton Data, Joy & Williams, Colorectal Dis 2002
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• 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
Fistulotomy and SetonsConclusions