CUTTING SETON WITHOUT PRELIMINARY INTERNAL SPHINCTEROTOMY IN MANAGEMENT OF COMPLEX HIGH FISTULA-IN-ANO

PURPOSE: The traditional treatment of a complex high fistula-in-ano by internal sphincterotomy and insertion of a cutting seton carries a ri sk of fecal incontinence. We have assessed the functional impact of tr eating patients with a complex fistula-in-ano by a cutting seton fistu lotomy technique that preserves the internal sphincter. METHODS: The o perative steps consisted of initial eradication of sepsis, identificat ion of the internal and external openings of the fistula tract, excisi on of the fistula tract with anal canal mucosa, and insertion of a cut ting silk seton around both the internal and external sphincters. In t his way open drainage of the intersphincteric space was avoided, and i ntegrity of the internal sphincter was maintained. Functional outcome following treatment with this technique, with regard to fistula eradic ation and effect on fecal continence was assessed in 27 patients (15 m ales) who were treated during a six-year period. Twenty-three patients (85 percent) had a history of previous fistula surgery. RESULTS: The fistula was cured in 26 patients (96 percent) with no reports of alter ed continence at the time of discharge from outpatient review. Recurre nce developed in one patient (4 percent) in whom hidradenitis suppurat iva was subsequently diagnosed. ALL four patients with Crohn's disease had their fistulas eradicated; three (75 percent) have subsequently u ndergone proctectomy for severe perianal and rectal Crohn's involvemen t. Long-term follow-up revealed three patients (19 percent, all rectov aginal fistulas) who experienced a deterioration in continence after d ischarge. CONCLUSIONS: Although this procedure may not be appropriate for rectovaginal fistulas, the data suggest that cutting setons are ef fective in treating complex fistula-in-ano, including those that have failed to respond to other forms of surgery. Avoidance of preliminary internal sphincterotomy may prevent deterioration in continence.