Seton drainage prior to transanal advancement flap repair: useful or not?

Abstract

IntroductionTransanal advancement flap repair (TAFR) provides a useful tool in the treatment of high transsphincteric fistulas. Recent studies indicate that TAFR fails in one out of three patients. Until now, no definite predictive factor for failure has been identified. Although some authors have reported that preoperative seton drainage might improve the outcome of TAFR, this could not be confirmed by others. We conducted the present study to assess the influence of preoperative seton drainage on the outcome of TAFR in a relatively large series.MethodsBetween December 1992 and June 2008, a consecutive series of 278 patients [M/F = 179:99, median age 46 years (range, 19–73 years)] with cryptoglandular, transsphincteric fistula, passing through the upper or middle third of the external anal sphincter underwent TAFR. Patients were recruited from the colorectal units of two university hospitals (Erasmus Medical Center, Rotterdam, n = 211; and Leiden University Medical Center, Leiden, n = 67). Baseline characteristics did not differ between the two clinics. Sixty-eight of these patients underwent preoperative seton drainage for at least 2 months and until the day of the flap repair.ResultsMedian healing time was 2.2 months. In patients without preoperative seton drainage, the healing rate was 63%, whereas the healing rate was 67% in patients who underwent preoperative seton drainage. This difference was not statistically significant. No differences in healing rates were found between the series from Leiden and Rotterdam.ConclusionPreoperative seton drainage does not improve the outcome of TAFR.

German S3 guideline: anal abscess

“…The value of a Seton drain has not been definitively agreed. Current publications [30][31][32], some of which are the subject of lively debate, do not indicate that placement of a Seton drain represents an advantage for successful plastic fistula closure.…”

The treatment of anal fistula: secondACPGBIPosition Statement – 2018

“…Early case series suggested efficacy in around 70% of patients [132][133][134][138][139][140][141][142][143][144]. However, more recent randomized controlled trial data, often vs the anal fistula plug, and larger series, suggest healing in a smaller proportion, perhaps of the order of 50-60% [145][146][147]. A recent multicentre randomized trial of 94 patients from Scandinavia found a primary success rate (defined as clinical healing), at a median of 12 months of follow-up, of 62% of 40 patients.…”

Loose Seton Technique as a Conventional Procedure for the Treatment of Anal Fistula and Long-Term Results

“…There are many proponents of loose seton procedure stating that this technique should be the gold standard in patients with a history of pelvic radiotherapy, recurrent fistulas, Crohn's disease, fistulas involving more than 50% of the external sphincter, multiple fistula tracts and complicated fistulas such as horseshoe fistula [10]. However, there is inadequate data on the effectiveness, patient tolerance and follow-up period of this treatment [11]. In our study, there were patients with horseshoe fistula, Crohn's disease and transsphincteric and multiple fistula tracts (Figure 1: Multiple Fistula Tracts, Figure 2: Opening Of Multiple Fistula Tracts).…”