Two Staged Operations using Loose Thick Seton Suture in the Treatment of High Type Fistula in Ano Stimulate Rapid Healing and Lower Recurrence Rate View PDF

*Samer Makki Mohamed Al-Hakkak
Department Of Surgery, Faculty Of Medicine, Jabir Ibn Hayyan Medical University, Najaf City, Iraq

*Corresponding Author:
Samer Makki Mohamed Al-Hakkak
Department Of Surgery, Faculty Of Medicine, Jabir Ibn Hayyan Medical University, Najaf City, Iraq
Email:Sammerhakak1971@yahoo.com

Published on: 2020-06-22

Abstract

Background: Fistula in ano is a chronic problem for the patients. It causes distressing because of foul odor and soiling with recurrent infection and discharge. Recurrence and anal sphincter injury were the most critical complications following surgery. Loose, thick Seton placement was the most promising surgical operation. To reduce the time of Seton placement, therefore, decreasing the suffering of patients from soiling and multiple dressing.
Patients and Methods: A retrospective study. One hundred patients with high type fistula in ano treated surgically in Al-Sader Medical city and Al-Najaf daily private clinic, Najaf city, Iraq from Feb 2018 to March 2019. Fistulography and magnetic resonance imaging have taken from all patients. After that, fistulectomy with loose, thick Seton suture placed for three months. Patients with the persistence of high fistula tract underwent a second surgery and third operation until complete healing.
Results: One hundred patients with high type fistula in ano with male 96 (96%) and female patients were 4 (4%). The rate of complete healing among male patients after the first operation was 90 (93%), while female patients showed a 4(100%) rate of complete healing after the first operation. Three of the remaining male patients with persistently high fistula tract showed complete healing after the second operation, whereas 3 (3%) the rate of complete healing was 100% after the third operation.
Conclusion: A Loose, thick Seton placed in high type fistula tract for three months provides excellent protection to the external anal sphincter with less recurrence rate and rapid healing.

Keywords

High Type Fistula in Ano, Loose Thick Seton, Recurrence, Staged Surgery, Healing Rate, Incontinence

Introduction

Anal Fistula is a track with an internal opening of the anal lining of the external opening in the perianal skin [1]. Fistula in ano is a chronic clinical problem. It had described by ancient medicine. It has been described in many old papers and books 2000 years before. Hippocrates (430 BCE) was the first person who represents the surgical treatment of anal fistula by using Seton [2]. Surgery is the definitive treatment. However, recurrence is the main problem [3]. The main challenges in treatment are preserving the function of the anal sphincter and heterogeneity of types [4,5]. The causes of an anal fistula are either idiopathic, iatrogenic, or secondary to another disease like inflammatory bowel disease [6]. An idiopathic anal fistula is the most common type and occurs in healthy subjects [7]. The crypto glandular the theory is the most acceptable for the generation of anal fistula. It is postulated as the initiating event in the development of a fistula is crypto glandular infection with subsequent suppuration [8]. The anal crypt glands situated at the level of dentate line and arranged circumferentially. They penetrate the internal sphincter into the intersphincteric plane. They provide the pathway for the infecting microorganism to penetrate the intramuscular area [9]. Spontaneous drainage of the abscess into the perianal skin may develop with subsequent granulation tissue lining the tract leading to recurrence of symptoms [10]. There are many classifications of fistula in ano, the most reliable one developed by the Parks and colleagues which depends on the anatomical site of the fistula [11]:

  • Intersphincteric
  • Transsphincteric
  • Suprasphincteric
  • Extrasphincteric

No medical treatment can eradicate the problem, but long term antibiotic prophylaxis with infliximab used for the treatment of recurrent fistula in patients with Crohn?s disease [12]. Therefore, surgery remains the first choice for the treatment of fistula in ano. The aims of surgical treatment are first: draining the infection and suppuration, second: the eradication of the fistulous tract and third: preserving anal sphincter function [13]. Patients with Crohn?s disease should be treated well before any surgical intervention [14]. The uncomplicated abscess must drain. Perianal ulcer increases the risk of fistula formation by two folds before the age of 40 years [15]. Fistulectomy with Seton placement is the primary step in surgical intervention. Seton placement can stage into single- and two-staged Seton placement. Unique staged Seton placement called cutting Seton placement as the Seton tightened with time leading to fibrosis [16]. The success rate is good with this type (about 82-100%), but the development of incontinence can exceed 30%. Two-staged Seton placement, which also called loose Seton placement, has a lower success rate of about 60-78% but with a lower risk of incontinence [17]. Plugs with fibrin glue and adhesives also have been used, but clinical trials showed that these approaches are not superior to Seton placement for a better success rate [18]. In our previous published work, we use thick loose Seton placement for about six months or even more. The approach was waiting until the sutures fall by itself. On the other hand, patients were complaining about soiling, multiple dressing, and bad hygiene. Therefore, this study aims to reduce the time of Seton placement for up to three months to reduce the patient’s complaint from Seton placement.

Materials and Methods

The study started in Feb 2018 and ended in March 2019. One hundred patients selected from the private Al-Najaf daily clinic and consultant clinic in Al-Sader Medical city, Najaf city, Iraq, as a high type fistula in ano. Whether presented either as recurrence or first-time presentation. The diagnosis made by using a computerized scan (CT scan), Fistulography, or MRI. Prospective collected data from all the patients and were analyzed retrospectively. Written consent takes from patients before operation. All patients were informed about doing fistulectomy and thick silk Seton suture placement for three months by excising the extrasphincteric part and putting the Seton suture to the intersphincteric part. Then, the second stage of operation includes the excision of the changing low type tract in which the silk Seton placed. We decrease the time of Seton placement in this study for three months to reduce the annoying symptoms of the patients. Therefore, the patient admitted to the operation theater after obtaining written consent. Most of the patients anesthetized by spinal anesthesia. In the operation theater, the patient assumed a lithotomy position. After that, the injection of a solution, which is a mixture of methylene blue dye and hydrogen peroxide into the external opening of the fistula, was done to find the internal opening. The exit of color dye or bubbles achieved to localized of inner opening from it after using intraoperative proctoscopy examination. Then, a metal probe introduced with four-folds, number 2 silk Seton suture. The Seton placement was limited to the remnant inter-sphincteric part and tying it loose in its place. The last steps in the theater were hemostasis and dressing. After discharge of patients, follow up was done every ten days with a prescription of suitable antibiotics and analgesia with local wash by normal saline and iodine soap twice daily. In six male patients, during the second stage operation, we found the fistula tract is still high despite Seton suture. So we change the old Seton, silk suture by a new one and wait for another three months. Then we brought them to third stage operation in which all of these changes to the low tract. We excised the lower tract and removed the second loose Seton suture (Table 1).

Table 1: Demographic characteristics of patients.

1

Gender

No.

%

Male

96

96.00%

Female

4

4.00%

2

Age

10-20 years

11

11.00%

20-30 years

35

35.00%

30-40 years

14

14.00%

40-50 years

20

20.00%

50-60 years

13

13.00%

60-70 years

7

7.00%

3

Mode of Presentation

First presentation

72

72.00%

Perianal abscess

3

3.00%

Previous Surgery

25

25.00%

 

 

 

4

Histopathology

Ulcerative colitis

 2

 2.00%

Chronic nonspecific inflammatory tract

 98

98%

Results

The total number of patients was one hundred. Most of the patients were male 96 (96%), while female patients were 4 (4%). Age distribution of patients showed that the highest rate of patients lies between the ages of 20-30 years. Then the age group of 40-50 years represents about 20% of patients. Most of the patients presented for the first time 72 (72%), while those who had previous surgery about 25 (25%) and only 3 (3%) who presented with perianal abscess. Only 2 (2%) had ulcerative colitis (Table 1) (Figures 1 to Figure 4). After surgery and follow up, about 90 male patients (93.75%), and all-female patients showed complete healing with the removal of Seton suture after three months (Table 2) (Figures 5 and Figure 6). After the second operation for the remaining six male patients, only 3 of them showed complete healing after removal of Seton suture by three months (complete healing 50% after the second operation) while the remaining three patients showed complete healing after the third operation.

Table 2: Percentage of Persistence of high fistula tract in patient through stages of Seton placement.

Operations 

First operation

Second operation

Third operation

Gender

Male

Female

Male

Female

Male

Female

Total Number of Patients

96

4

6

0

3

0

Complete Healing

90(93.7%)

4(100%)

3(3.15%)    

0

3(3.15%)

0

Persistence of High Fistula Tract

6(6.3%)

0(0%)

6(6.3%)

0

3(3.15%)

0

Discussion

Perianal fistula is an embarrassing problem for the patients because of soiling and lousy odor in addition to recurrent infection and abscess formation [19]. The best treatment is surgical intervention. However, recurrence and sphincter incontinence is still a challenge. Several surgical approaches have developed to overcome this problem by inserting loose, thick silk Seton suture in the fistula tract [20]. The loose Seton will remain for a long time. This study concentrates on the time of Seton suture persistence in the lower part of the high type fistula in ano tract. The majority of patients in the previous study complained of the long-lasting existence of Seton suture, which caused soiling, discomfort, bad odor, and itching in addition to many medical visits and dressing. Therefore, it was necessary to reduce the time of Seton placement, promote healing, and rapid release to work and healthy life. Meanwhile, in both studies, the primary goals were to protect external anal sphincter and to lower the recurrence rate. In the present study, the patients showed a complete healing rate of 94% after the first surgery in comparison to published research, which showed a perfect healing rate of 91.2%. This difference is small and may reflect the mild improvement in the success rate with a short time of sutures stay. Both studies did not record any post-operative sphincter incontinence. In the present study, there was a difference in the rate of healing after the second operation (which was 50%) in comparison to the previous research (which was 82%). This difference owned at the time of loose, thick Seton placement as it was three months in the present study while it was more than six months in the previous survey. In our last research, there was enough time for fibrous tissue formation. Six months of Seton placement in the fistula tract were distressing for the patients calling for the introduction of this research. The conversion of high type fistula into low type due to insertion of loose, thick Seton spares the sphincter. It induces healing by a chronic inflammatory reaction, granulation tissue formation, and fibrous tissue precipitation [20]. This process will enhance healing. On the other hand, pus formation, soiling, and multiple dressing were annoying for the patients. This study showed that loose, thick Seton placement in the fistula tract for three months provides excellent protection to the external anal sphincter with less recurrence rate and less annoying symptoms to the patients and rapid release to a healthy life. Finally, we recommend this type of work of loose Seton suture for three months because of proper protection to sphincter function and low rate of recurrence.

Conclusion

Using, loose thick Seton in treatment of high type fistula in ano is safe procedure with less recurrent rate, less incontinence and good healing. Staging surgery with use of loose thick Seton suture promote good result with rapid time of healing and no more waiting time for spontaneous suture fail.

Declarations

Ethical consent has been taken from all patients.

Consent for Publication

Consent has been taken from the institution and the patients.

Materials and Data

The data used and/or resolved during the current study are ready from the corresponding author on need.

Competing Interests

All authors stat they don’t have any conflict of interest.

Funding

Authors declare not received any funds from any source.

Ethical Approval

The ethical committee of the, Faculty of Medicine, Jabir Ibn Hayyan Medical University.

References

  1. Saadeldin I, Arafa E, Hassan A, Aamir H (2015) Classification of fistula in ano. Med J 2: 99-102.
  2. Corman ML, Nicholls RJ, Fazio VW, Bergamaschi R (2013) Corman's colon and rectal surgery (6th edtn), Lippincott Williams & Wilkins, Wolters Kluwer business, Philadelphia, United States.
  3. Af?arlar ÇE, Karaman A, Tan?r G, Karaman ?, Y?lmaz E, et al. (2011) Perianal abscess and fistula-in-ano in children: clinical characteristic, management and outcome. Pediatr Surg Int 27: 1063?1068.
  4. Abbas MA, Lemus-Rangel R, Hamadani A (2008) Long-term outcome of endorectal advancement flap for complex anorectal fistulae. Am Surg 74: 921?924.
  5. Phillips J, Lees N, Arnall F (2015) Current management of fistula-in-ano. Br J Hosp Med 76: 142-147.
  6. Ross ST (1988) Fistula in ano. Surg Clin North Am 68: 1417?1426.
  7. Hancock BD (1992) ABC of colorectal diseases. Anal fissures and fistulas. BMJ 304: 904?907.
  8. Hämäläinen KP, Sainio AP (1998) Incidence of fistulas after drainage of acute anorectal abscesses. Dis Colon Rectum 41: 1357?1362.
  9. Rosen L (1994) Anorectal abscess-fistulae. Surg Clin North Am 74: 1293?1308.
  10. Vogel JD, Johnson EK, Morris AM, Paquette IM, Saclarides TJ, et al. (2016) Clinical practice guideline for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula. Dis Colon Rectum 59: 1117?1133.
  11. Parks AG, Gordon PH, Hardcastle JD (1976) A classification of fistula-in-ano. Br J Surg 63: 1?12.
  12. Present DH, Rutgeerts P, Targan S, Hanauer SB, Mayer L, et al. (1999) Infliximab for the treatment of fistulas in patients with Crohn's disease. N Engl J Med 340: 1398?1405.
  13. Seow-Choen F, Nicholls RJ (1992) Anal fistula. Br J Surg 79: 197?205.
  14. Marzo M, Felice C, Pugliese D, Andrisani G, Mocci G, et al. (2015) World J Gastroenterol 21: 1394-1403.
  15. Davis BR, Kasten KR (2016) Anorectal abscess and fistula. The ASCRS Textbook of Colon and Rectal Surgery (3rd edtn), Springer, New York, United States.
  16. McCourtney JS, Finlay IG (1995) Setons in the surgical management of fistula in ano. Br J Surg 82: 448?452.
  17. Memon AA, Murtaza G, Azami R, Zafar H, Chawla T, et al. (2011) Treatment of complex fistula in ano with cable-tie Seton: a prospective case series. ISRN Surg 2011: 636952.
  18. Chung W, Kazemi P, Ko D, Sun C, Brown CJ, et al. (2009) Anal fistula plug and fibrin glue versus conventional treatment in repair of complex anal fistulas. Am J Surg 197: 604?608.
  19. Sangwan YP, Rosen L, Riether RD, Stasik JJ, Sheets JA, et al. (1994) Is simple fistula-in-ano simple?. Dis Colon Rectum 37: 885?889.
  20. Ho YH, Tan M, Leong AF, Seow-Choen F (1998) Marsupialization of fistulotomy wounds improves healing: a randomized controlled trial. Br J Surg 85: 105?107.
scroll up