Anal Fistula Seton – Treatment Explained
An anal fistula seton is a surgical technique for treating anal fistulas, in which a thread or suture is passed through the fistula tract to promote gradual healing.
Things worth knowing about "Anal Fistula Seton"
An anal fistula seton is a surgical technique for treating anal fistulas, in which a thread or suture is passed through the fistula tract to promote gradual healing.
What Is an Anal Fistula Seton?
An anal fistula seton is a well-established surgical method used in the treatment of anal fistulas. An anal fistula is an abnormal tunnel connecting the anal canal or rectum to the skin surface around the anus. A seton – typically a thread, silicone band, or suture material – is passed through this fistula tract. The technique aims to either gradually divide the sphincter muscle in a controlled manner or to drain the tract and reduce inflammation while preserving continence.
Types of Seton
Cutting Seton
A cutting seton is progressively tightened at regular intervals of several weeks. This slowly cuts through the sphincter muscle while simultaneously allowing scar tissue to form, which helps maintain continence. This method is commonly used for high or complex anal fistulas that involve a significant portion of the sphincter.
Loose (Draining) Seton
A loose seton is placed loosely through the fistula tract and left in place for an extended period. It keeps the tract open, allowing continuous drainage of secretions and pus, thereby reducing inflammation and preparing the tissue for a later definitive surgical procedure. This approach is frequently used in patients with Crohn disease or particularly complex fistulas.
When Is a Seton Used?
Seton placement is indicated in the following situations:
- High anal fistulas that traverse a significant portion of the sphincter muscle
- Complex or branching fistula tracts
- Perianal fistulas associated with Crohn disease
- Patients at elevated risk of postoperative fecal incontinence
- As a bridge to further surgical intervention (e.g., advancement flap, LIFT procedure)
Diagnosis and Preoperative Assessment
Before seton placement, the fistula is carefully evaluated. Diagnostic methods include:
- Proctological examination: Visual inspection and digital rectal examination
- Endoanal ultrasound: Visualization of the fistula tract and its relationship to the sphincter
- Pelvic MRI: Particularly valuable for deep or complex fistulas to define anatomy precisely
- Fistula probe examination performed intraoperatively
Surgical Procedure
The procedure is typically performed under spinal or general anesthesia. The surgeon identifies the fistula tract using a specialized probe and threads the seton – usually a silicone vessel loop, nylon tape, or absorbable suture – through the tract. The ends of the thread are tied together or secured outside the body. With a cutting seton, the thread is progressively tightened during outpatient follow-up visits.
Benefits and Risks
Benefits
- Protection of the sphincter muscle and prevention of incontinence
- Controlled, stepwise tissue healing
- Effective drainage in cases of ongoing inflammation
- Suitable for complex and recurrent fistulas
Risks and Side Effects
- Temporary pain and sensation of a foreign body in the anal region
- Possible infection or inflammation around the seton
- Risk of sphincter impairment in rare cases despite careful technique
- Potential fistula recurrence after seton removal
- Longer treatment duration compared to direct surgical approaches
Aftercare and Healing
Following seton placement, regular follow-up appointments are essential. Patients are advised to maintain good anal hygiene, for example through regular sitz baths. With a cutting seton, the thread is tightened every two to six weeks. The total treatment period may extend over several months. After completion of seton therapy, a further surgical procedure is often required to achieve definitive closure of the fistula.
References
- Vogel J.D. et al. – Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Diseases of the Colon & Rectum, 2016.
- Ommer A. et al. – S3 Guidelines for Cryptoglandular Anal Fistulas, German Society of Coloproctology (DGK), 2016.
- Parks A.G., Gordon P.H., Hardcastle J.D. – A classification of fistula-in-ano. British Journal of Surgery, 1976.
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