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16 The Seton in Anal Fistula Management 263
Table 3 (continued)
Italian Society of Colorectal Surgery (SICCR)
2020 (Amato et al. 2020)
Japanese Guidelines 2018 (Yamana 2018) Several approaches are utilized for anal
Simple fistula (intersphincteric tracks or
single transsphincteric tracks that cross less
than 30% of the external sphincter): loose inert
setons and chemical setons should not be used
since they are associated with longer healing
times and more postoperative pain
Grade of recommendation: 1B
Complex fistula: draining seton can be used
before a sphincter-saving procedure
Grade of recommendation: 2C
fistulas. A specific procedure may be chosen
depending upon curability and anal function.
Postsurgical outcomes vary from study to
study
Subcutaneous fistulas (Type I), low
intersphincteric fistulas (Type II): The seton
method is effective both in terms of radicality
and sphincter function preservation
Recommendation: B
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Abdelnaby M, Emile S, El-Said M, Abdallah E, AbdelMawla A (2019) Drained mucosal advance-
ment flap versus rerouting seton around the internal anal sphincter in treatment of high transsphincteric anal fistula: a randomized trial. Int J Surg 72:198–203
Akici M, Ersen O (2020) The effect of suture selection in complex anal fistulas on the success of
cutting seton placement and patient comfort. Pak J Med Sci 36:816–820
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and management of perianal abscess and anal fistula: SICCR position statement. Tech
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1121–1123
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outcome following loose-seton technique for external sphincter preservation in complex anal
fistula. Br J Surg 91:476–480
Daodu OO, O’Keefe J, Heine JA (2018) Draining setons as definitive management of fistula-in-ano.
Dis Colon Rectum 61:499–503
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and consensus on perianal fistula: an analysis of national and international guidelines. Colorectal
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Emile SH, Elfeki H, Thabet W, Sakr A, Magdy A, El-Hamed TMA, Omar W, Khafagy W (2017)
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1372
Fistulotomy
17
Paola Campennı`, Lorenzo Ferri, Angelo Parello, Francesco Litta,
Veronica De Simone, Angelo Alessandro Marra, and Carlo Ratto
Contents
1 Introduction .................... ............................... ............................. 266
2 Indications . ............... .................................................................. 267
3 Fistulotomy: Standard Technique .......................................................... 268
4 Other Fistulotomy Techniques ............................... .............................. 268
4.1 Addition of Loose Seton ....... ...................................................... 268
4.2 Slow Dissection of the Sphincter: Cutting Seton ................................... 269
4.3 Addition of Marsupialization ...................... .................................. 270
5 Fistulotomy with Immediate Primary Sphincteroplasty (FIPS) ........................... 270
6 Fistulotomy in Crohn’s Disease (CD) ... . . . . ....... . . . . ...... . . . . ....... . . . . ....... . . . . ... 274
7 Postoperative Care ...................................... ................................... 275
8 Complications and Recurrence Rate ....................................................... 276
9 Discussion ............................................................ ...................... 278
10 Conclusion .................... ................................. ............................ 281
References ............................ ............................................... ............ 281
Abstract
The treatment of anal fistula has been found in the oldest medical texts of
Hippocrates. Since then, the management of the anal fistula has remained almost
unchanged, but in the last 30 years sphincter-sparing minimally invasive
P. Campennì · A. Parello · F. Litta · V. De Simone
Proctology Unit, Dept. of Medical and Surgical Sciences, Foundation University Hospital
“A. Gemelli”, IRCCS, Rome, Italy
e-mail: paola.campenni@policlinicogemelli.it ; angelo.parello@proctocenter.it
L. Ferri · A. A. Marra
Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo
A. Gemelli, Rome, Italy
C. Ratto (
Proctology Unit, Dept. of Medical and Surgical Sciences, Foundation University Hospital
“A. Gemelli”, IRCCS, Rome, Italy
Catholic University, Rome, Italy
© Springer Nature Switzerland AG 2022
C. Ratto et al. (eds.), Anal Fistula and Abscess, Coloproctology,
https://doi.org/10.1007/978-3-030-76670-2_19
*)
265
266 P. Campennı`et al.
operations have been proposed reporting variable results. Although several international guidelines for the diagnosis and treatment of anal fistula have been
published, many aspects remain controversial or undefined due to poor clinical
evidences in literature.
Fistulotomy was one of the first techniques described and is still considered
valid. This procedure provides laying open the fistula tract and healing the wound
by secondary intention. Although the high probability of fistula healing is well
known (ranging between 85 to 98%), the risks of fecal incontinence, keyhole
deformation of the anus, and, in some cases, long wound healing times are
frequently observed and should not be underestimated. Recent literature data
have shown a fecal incontinence rate ranging between 6 to 28% in low fistula and
17.5 to 40% in high fistula.
To avoid these risks, the correct patients selection is mandatory, evaluating in
each case the position of the internal orifice, the height of the fistulous tract in
relation to the sphincters, and the functional integrity of the sphincters. Then, not all
fistulotomies can be considered the same. Some surgeons offer only a lay-open,
providing the spontaneous wound healing, others after fistulotomy performing a
marsupialization with a series of sutures on the border of the surgical wound, while
others prefer to add an immediate anal sphincters reconstruction.
The lack of standardization of the technique is currently source of debate,
mainly considering the opinion discrepancies of both patients and surgeons about
the perspectives of healing and the risks of continence impairment following the
fistulotomy.
This chapter is aimed to critically analyze the literature data on fistulotomy in
terms of efficacy, impairment of continence, and impact on patient’s quality of life.
1 Introduction
Among all the different kinds of treatment for anal fistula, fistulotomy stands as the
oldest. References to surgical treatment of anal fistulas date back to 400 BC, when
Hippocrates described the use of setons. A more thorough examination of the
surgical alternatives for anal fistula can be attributed to John Arderne, an English
surgeon who wrote Treatises of Fistula in Ano; Haemmorhoids, and Clysters (1376).
In the last two centuries many surgeons have contributed in the study, treatment,
and classification of anal fistulas. Among them, Goodsall, Miles, Milligan, Morgan,
and Parks must be mentioned; in particular, the Park’s classification, published in
1976, is still most commonly used.
Still today, fistulotomy is the most used surgical procedure in the treatment of anal
fistulas. It is considered simple and effective, as it only requires cutting the skin, mucosa,
and a limited portion of the sphincters; however, it is also potentially dangerous.
Currently, several different techniques of fistulotomy are reported with non-
homogeneous results regarding healing rate, recurrences, and complications
(Amato et al. 2020).
Each patient must be carefully explored and both the fistula tract and the anal
sphincters must be evaluated, as correlated each other. At first inspection the
17 Fistulotomy 267
external opening should be identified, although it may not appear clearly due to the
inflammatory process. If suppuration is still active, an external opening at perianal
skin may exist, and an abscess can be appreciated instead. At digital examination
the fistula tract fells like a hardened cordon, and the internal opening as a tough
spot in the anal canal ; its identification allows to estimate the involvement of the
sphincter muscle.
Endoanal ultrasonography is a less expensive outpatient-setting tool that allows
detailed study of the type and number of fistulas; hydrogen peroxide may be used as
contrast to highlight the course. In cases where endoanal ultrasound is not feasible or
leaves diagnostic doubts, MRI of the pelvis should be performed.
As preparation to surgery, mechanical cleaning of the anal canal and low rectum
is suggested. In our experience an enema shortly before surgery is enough to
guarantee a cleaner field and better visibility.
Antibiotic prophylaxis should follow local guidelines, but is not strictly indicated.
Deep sedation and general anesthesia are to be preferred, as they allo w total patient
collaboration, near-total control of pain and relaxation of the anal sphincter. Local
anesthesia is used as an implementation to the postoperative pain control regime.
More recently, local anesthesia has also been proposed to perform fistulotomy. In
fact, in highly specialized centers with dedicated and expert staff, it is considered a
safe and effective practice. However, it can lead to great patient’s discomfort and
prolongs the duration of the procedure due to repeated anesthetic injection, suboptimal collaboration, and pain control.
2 Indications
The use of fistulotomy, as any other option to treat anal fistulas, should be finely
tailored to each patient and his/her own condit ion. While it remains strongly
indicated for simple fistulas (those with a single tract and less than 30% of the
external sphincter interested), its use for complex fistulas is linked to a significantly
higher rate of continence impairment and recurrence.
Fistula site and the patient gender are also a matter for decision. According to
guidelines, the anterior fistula in women is considered complex, because it may
interest pivotal anatomical structures that could be involved in the cutting process.
Previous surgery, recurrent disease, impaired continence, pelvic irradiation, or
local tuberculosis per definition renders the fistula as complex.
Thus, following Parks classification, fistulotomy should be indicated for
intersphincteric (no external sphincter involved) and low transphincteric fistulas
(less than 30% of the external sphincter involved).
Contraindications to fistulotomy should be the anterior fistulas in woman, high
transphincteric fistulas, and all complex anal fistulas. In case of a horseshoe fistula
fistulotomy is contraindicated, given the exceptionally high risk of recurrence due to
the multiple tracts. Recurrence after fistulotomy is also directly linked to the number
of previous interventions and is thus contraindicated for multiple operations and
failure to find the internal opening of the fistula tract leads to an elevate risk of
recurrence.
268 P. Campennı`et al.
For patients with Crohn’s disease medical treatment is the first choice for anal
fistula, while surgery is reserved as a last resort for infection control; in this case
fistulotomy is not the first surgical option, and a sphincter-sparing procedure should
be preferred, although burdened with a rate of major complications and recurrences.
However, an adequate counseling with the patient is necessary before any
operation, explaining risks and complications, and sharing the therapeutic strategy.
3 Fistulotomy: Standard Technique
Patients can be positioned in the modified lithotomy position, jack-knife position, or
prone position. The lithotomy position is our standard choice as it allows a complete
examination of anal and perianal region; it also allows easier airways control during
the anesthesia.
Digital exploration is performed; under anesthesia the contractile tone of the
sphincter is loosened, and it may be easier to identify the internal and external
openings and study the fistula tract. Particular importance must be given to finding
the internal and external sphincter and the transition zone between one and the other,
the so-called intersphi ncteric groove. This is key to estimating the sphin cter’s
involvement in the fistula and consequently to choosing the right approach.
An operative anoscope is inserted and all the quadrants of the anal canal are
explored. External and internal openings should be always recognized, both visually
and with palpation. When in doubt, injection of hydrogen peroxide helps highlight
the internal orifice.
The fistula tract is identified using linear or curved probes. When possible probes
should be inserted in the internal opening and passed all the way through the external
one. Contrarily, inserting the probe in the external opening raises the risk of creating
a false tract or causing injuries; Goodsall’s rule is an effective practical guideline in
predicting a more curved or straight tract.
All the fistula tracts must be identified and their course should be clear before
attempting fistulotomy, which can be performed using said probes as a guide. Before
fistulotomy, curettage of the fistula tract may be performed.
Skin, mucosa, and sphincter fibers are completely divided. This division is nowadays
performed through electrocautery, which allows both cutting of the structures and
coagulation of small vessels. The surface of the fistula tract is thus exposed and flattened.
If needed, curettage and hemostasis can be adequately performed on the laid open
fistula.
4 Other Fistulotomy Techniques
4.1 Addition of Loose Seton
A seton is any tool, be it a vessel loop or a non-absorbable suture, that allows to
maintain the fistula tract patent. This is particularly useful when treating complex or
multiple tracts fistula, situations that very frequently require a multiple-stage
17 Fistulotomy 269
approach. The seton acts as a guide for future identification of the tract and, being a
foreign object, slows down the process of scarification while allowing the drainage
of blood and pus.
With the help of probes (hole-tipped one for sutures), the seton is passed through
the tract and is ligated to itself in a safe, enduring way and left loose (Figs. 1 and 2).
The placement of setons may lead to a worse quality of life for patients; while it is
usually tolerated, some patients refer discomfort or outright pain. These are caused
mainly by the knot, which is the most bulky part of the structure. In order to mitigate
the side effects many knot-less setons have been produced, such as the self-locking
ones; the absence of knots, however, leads to a higher risk of losing the seton itself.
Nonetheless seton positioning has not been proved effective in reducing recur-
rence rates (50%) and it is unhelpful in preventing fecal incontinence.
4.2 Slow Dissection of the Sphincter: Cutting Seton
An alternative to loose setons, cutting setons have been used especiall y for high
fistulas with an involvement of a long part of sphincters. The technical difference lies
in the tightness used for the ligation, as the cutting seton drives a slow division of the
Fig. 1 A loose seton was
previously placed to drain the
previous anal abscess and
prepare the following anal
fistula to the actual second
stage operation
Fig. 2 After removal of the
seton, the transphincteric anal
fistula is identified by a fistula
probe at the posterior anal
canal
270 P. Campennı`et al.
Fig. 3 Following the lay
open of skin-mucosasubmucosa layers, the internal
and external anal sphincters
below the fistula tract are
exposed, and the fistulotomy
is started from the internal
anal sphincter
sphincter trough a continuous pressure on the tissues. This pressure is guaranteed by
a periodical tightening of the seton itself.
The main mechanism of action of the cutting approach is double: on one side the
seton slowly but progressively cuts through the sphincter while, on the other side, it
leaves behind the front of tissue repair. Practice and literature has taught us that this
tissue repair is not effective enough to guarantee sphincter preservation, and incontinence remains a reality; logically, the rate of fecal incontinence is directly proportional to the speed of cutting.
The high rates of incontinence and the compromising effects on the quality of life
have led to consider the use of cutting setons not recommendable.
4.3 Addition of Marsupialization
Marsupialization is an optional, additional step to fistulotomy. Once the fistula tract
is laid open, continuity between the bed of the tract and the atmosphere is guaranteed
by a series of sutures on the border of the surgical wound. Scarring and wound
closure is thus controlled, limiting the appearance of anal deformities; drainage of
the fistula is optimal and results in a shorter healing time when compared to
fistulotomy. Studies have shown that continence impairment is reduced, while
recurrence rate is comparable (Fig. 3).
5 Fistulotomy with Immediate Primary Sphincteroplasty (FIPS)
About 30 years ago, Parkash et al. proposed sphincter reconstruction after
fistulotomy, to minimize the risk of postoperative anal deformation, disturbances
of fecal continence, and reduce the healing time.
It stands as an alternative to seton positioning and marsupialization.
17 Fistulotomy 271
Usually sphincter reconstruction is consequential to the act of fistulotomy and is
thus referred to as Fistulotomy with Immediate Primary Sphincteroplasty (FIPS).
Seton, if present, is removed, the internal fistula opening and fistula tract are
identified. A complete fistulotomy of the primary tract is carried out and the primary
tract is curetted in order to remove any granulation tissue. An end-to-end primary
sphincteroplasty is then performed using a series of interrupted absorbable stitches.
In case of intersphincteric fistulas, each stitch encompasses the internal anal sphincter and fistula tract; in case of transphincteric fistulas, both sphincters and fistula tract
are encompassed by the suture (Figs. 4, 5, and 6). Anal mucosa and submucosa are
continuously sutured with an absorbable suture, while keeping an external wound
drain (Ratto et al. 2021).
A long follow-up period is of crucial importance to evaluate the outcomes of any
fistula surgery. Indeed, a fistula may be inappropriately considered as “healed” when
it is just “silen t” in the short term. This has been clearly demonstrated by van der
Hagen et al., who demonstrated that the fistulotomy or endorectal flap recurrence rate
significantly increased over time. For this reason, in our recent study on efficacy and
patient satisfaction after FIPS (Litta et al. 2019), the analyses were restricted to
patients with a minimum follow-up of 12 months. In our cohort, the primary healing
rate was 93% with a mean follow-up of 56 months, reaching 95% after redo FIPS
was performed to treat recurrences. These data became more relevant focusing on
fistula complexity, which was diagnosed in half of our patients.
In 2015 a systematic review aimed to evaluate the evidence in the literature
supporting the use of this technique in the treatment of complex anal fi stulas was
conducted by our group (Ratto et al. 2015). This systematic review pooled the results
of 14 studies and showed a detailed clinical outcome of 666 patients with complex
anal fistula that underwent to FIPS procedure. The overall quality of the studies was
low, but five were prospective studies, and one was a randomized clinical trial.
Fig. 4 The fistulotomy was
completed; the transphincteric
fistula tract was curetted and
the inflammatory tissue
removed by diatermy
272 P. Campennı`et al.
Fig. 5 The immediate
sphincter repaired including
both the internal and external
anal sphincters
Fig. 6 The sphincter repair is
completed. A suture of the
mucosa-submucosa-skin layes
will follow
The male/female ratio, when reported, was almost 2 (277:142), and the fistula
etiology was crypt oglandular in the vast majority of patients (97.6%, 568 out of
580). The treated fistula was defined as complex in 501 patients (75.2%) and
recurrent in 107 patients (16.1%). The use of preoperative seton drainage, described
in only four studies, ranged from 40.3 to 100%. The analysis of data showed a
consistency of results across the studies analyzed, regardless of the surgeon
performing the FIPS procedure and the year of publication. Moreover, the success
rate was not related to either the type of fistula excision or sphincter reconstruction
modality.
The weighted average follow-up was 28.9 months (range 12–81 months); the
weighted average success rate was 93.2%, ranging from 85.7 to 100%. Eight reports
showed the time to recurrence, with a weighted average value of 8.9 months (range
1.5–20.0 months). The weighted average rate of sphincter dehiscence (which is
regarded as the most feared postoperative complication related to FIPS) was 2.2%,
and it ranged from 0 to 8.3%. Other minor reported postoperative complications
were: proctalgia or defecation disorders, urinary retention, fecal impaction, anal