Seventy-four patients who underwent seton treatment of high anal fistulae over a 6-year period have been reviewed. Four different techniques were used: staged fistulotomy (n = 24), cutting seton (n = 13), short-term seton drainage (n = 14) and long-term seton drainage in patients with Crohn's disease (n = 23). Recurrence developed in two patients (8 per cent) undergoing two-stage fistulotomy; two patients (14 per cent) undergoing short-term drainage and nine (39 per cent) of the patients with Crohn's disease. Three patients with Crohn's disease required proctectomy for progressive perianal disease. The remaining 11 patients with Crohn's disease (48 per cent) obtained a good result. None of the patients treated with a cutting seton developed a recurrence. Minor incontinence developed in 13 patients (54 per cent) undergoing two-stage fistulotomy and seven patients (54 per cent) treated with a cutting seton. When sphincter muscle was not divided, five patients (36 per cent) undergoing short-term drainage and six patients (26 per cent) undergoing long-term drainage developed minor incontinence. High complex fistulae can be successfully treated with only minor loss of continence using different seton techniques. In high Crohn's fistulae, long-term seton drainage preserves sphincter function, but recurrence is common if the seton is removed.

Both techniques are equally effective in eradicating the fistula, and both are associated with a similar rate of incontinence.

Ligation of the intersphincteric fistula tract is a new sphincter-sparing procedure for complex transsphincteric fistula. The success rate is comparable with other sphincter-preserving techniques. Importantly, it appeared to effectively preserve continence. Adding safe, muscle-sparing surgical options to our armamentarium for dealing with transsphincteric fistula is essential. Additionally, the procedure is easy to learn and has very low cost. Long-term follow-up and randomized, controlled trials are necessary to assess efficacy and durability.

No abstract

The results of 81 endorectal flap advancements for simple rectovaginal fistulas are reported. Simple fistulas are defined as less than 2.5 cm in diameter, low or mid vaginal septum in location, and infectious or traumatic in origin. Essentially, the technique is advancement of a flap of mucosa, submucosa, and circular muscle over midline approximation of internal sphincter muscle. The mean patient age was 34 years old (range, 18 to 76 years). The causes were obstetrical injury (74 percent), perineal infection (10 percent), operative trauma (7 percent), and unknown (8 percent). Overall, the repair was successful in 83 percent of patients. Success correlated with the number of previous repairs, i.e., none: 88 percent success; one: 85 percent success; two: 55 percent success. There were 25 concomitant overlapping sphincteroplasty procedures. Only minor complications ensued, with no mortality. This repair is recommended for patients with no or one previous repair because of its lack of mortality, minimal morbidity, ease of concomitant sphincteroplasty, and avoidance of a colostomy. For patients with two or more earlier repairs, a muscle interposition should be considered.