1. Fistulotomy and Setons Mr Graham Williams Consultant Colorectal Surgeon Royal Wolverhampton Hospitals NHS Trust

2. Surgical Treatment of Anal Fistulas

3. Anal Fistula Eradicate fistula Maintain continence Aims of Surgical Treatment

4. AuthorDateNumberRecurrence Hill1967626 6 (1%) Ani & Solanke19768214 (17%) Kuijpers198251 2 (4%) Gingold198374 1 (1%) Kronborg198526 3 (11%) Lilius1986150 8 (5.5%) Shouler1986115 8 (7%) Anal Fistula Surgery Results of Fistulotomy

5. Anal Fistula Surgery Problems Following Fistulotomy Extensive wound & delayed healing Gutter / key hole deformity Anal incontinence – Flatus (10% - 20%) – Soiling (5% - 10%) – Urgency – Faecal incontinence

6. Anal Fistula Surgery When is it Safe to Lay Open A D C B

7. Anal Fistula Surgery What is a High Fistula Sphincter muscle involved Site (anterior vs posterior) Male or female Previous anorectal surgery Associated diseases (eg Crohn’s)

8. Anal Fistula Surgery Seton Techniques As a marker of the tract As a long-term drain Two stage fistulotomy Snug seton (long-term cutting) Tight seton (cutting)

9. Anal Fistula Surgery Results 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

10. Loose Seton Long term Results 6 months>10 years 20 4 13 20 Total Free of Sepsis Number of Patients Buchanan et al, St mark’s Hospital, BJS 2004

11. Anal Fistula Surgery Results of Cutting Seton

12. Seton Fistulotomy Cutting v Two Stage Garcia-Aguilar et al 1998. BJS

13. Total Healed Loose setonCutting seton NUMBER Fistula Healing Outcome of Anal Fistula Surgery Results - Clinical Review 75% 96% 12 17 Wolverhampton Data, Joy & Williams, Colorectal Dis 2002

14. Total “Full Control” Loose setonCutting seton NUMBER Continence Outcome of Anal Fistula Surgery Results - Clinical Review 91% 94% 23 17 Wolverhampton Data, Joy & Williams, Colorectal Dis 2002

15. Pre-operative Post-operative Normal Incontinent flatus Incontinent liquid NUMBER Outcome of Anal Fistula Surgery Continence - 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

16. Pre-operative Post-operative NUMBER Outcome of Anal Fistula Surgery Continence - Questionnaire survey Cutting Seton 10/17 (59%) 90% 10% 50% 20% 30% Normal Incontinent flatus Incontinent liquid Incontinent solid 9 1 55 3 2 Wolverhampton Data, Joy & Williams, Colorectal Dis 2002

17. 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 Setons Conclusions