The anorectal fistula is a disease requiring careful assessment of the local signs and precise localization of the fistula channel. The Seton procedure for treatment of the fistula-in-ano we apply only for the management of trans- or extrasphincteric anorectal fistula. 152 patients with high trans- or extrasphincteric fistula-in-ano were operated. Men were 123/80.92%/, women-29/19.08%/. In 70 /46.05%/ fistula were extrasphincteric, while in 82/53.95%/ they were transsphincteric. Ba sic step is to identify the internal opening of the fistula channel following Goodsal`s rule. The Seton is trespassed through the internal opening and we tight it moderately. Every next tightening is performed at 3 days intervals. Recurrences ware registered in the first 6 months in 8 patients/5.26%/. We conclude that that seton procedure for treatment of trans- and extrasphincteric fistula is an easy to learn and practice radical one stage surgical method with a cure rate of nearly 95%. Elastic Seton ligation technique is a modification of the known from ancient times conventional ligation procedure. The following procedure is an effective method for difficult and high fistula-in-ano

Hadzhiev, B.

Ivanov, I.

Sakakushev, B.

Todorov, A.

English

Varna Medical University Press: Journals

ELASTIC SETON PROCEDURE FOR SURGICAL TREATMENT OFANORECTAL FISTULASB. Hadzhiev, B. Sakakushev, A.Todorov, Iv. IvanovMedical University Plovdiv, University Hospital St. George, Clinic of General Surgery with ColoproctololgyABSTRACTThe anorectal fis tula is a dis ease re quir ing care ful as sess ment of the lo cal signs and pre cise lo cal iza tion of thefis tula chan nel. The Seton pro ce dure for treat ment of the fis tula-in-ano we ap ply only for the man age ment oftrans- or extrasphincteric anorectal fis tula. 152 pa tients with high trans- or extrasphincteric fis tula-in-anowere op er ated. Men were 123/80.92%/, women-29/19.08%/. In 70 /46.05%/ fis tula were extrasphincteric,while in 82/53.95%/ they were transsphincteric. Ba sic step is to iden tify the in ter nal open ing of the fis tulachan nel fol low ing Goodsal’s rule. The Seton is tres passed through the in ter nal open ing and we tight it mod er -ately. Ev ery next tight en ing is per formed at 3 days in ter vals. Re cur rences ware reg is tered in the first 6 months in 8 pa tients/5.26%/ . We con clude that that seton pro ce dure for treat ment of trans- and extrasphincteric fis -tula is an easy to learn and prac tice rad i cal one stage sur gi cal method with a cure rate of nearly 95%.Elas ticSeton li ga tion tech nique is a mod i fi ca tion of the known from an cient times con ven tional li ga tion pro ce dure.The fol low ing pro ce dure is an ef fec tive method for dif fi cult and high fis tula-in-ano. Key words: Anorectal Fis tula (ARF), Anorectal Ab scess (ARA)INTRODUCTIONThe anorectal fistulae (ARF) are chronic con se quence af terspon ta ne ous or non rad i cal op er a tive ab scess drain age inthe perianal re gion/1/. Even wide drain age of the anorectalab scess (ARA) af ter ha bit ual per fo ra tion, its in ter nal open -ing re mains in the anal chan nel, in crim i nat ing per sis tent in -flam ma tory pro cess from the patho gen flora in the rec tum.In cases of microincisions per formed by less ex pe ri encedsur geons, re sid ual ab scess leads to fis tula for ma tion/1,2/.The in flam ma tory pro cess in ARF starts from the in ter nalopen ing of the crypts of Mor gan, fol low ing the fis tulachan nel through the pararectal tis sues, ter mi nat ing with anex ter nal open ing in the perianal re gion/1,3,4/. While sur gi cal treat ment of intrasphincteric and lowtranssphincteric fistulae is clearly de ter mined and has goodpost op er a tive re sults, the man age ment of hightranssphincteric and extrasphincteric ARF is not rarelyprob lem atic with un sat is fac tory re sults due to con tin u oustreat ment, of ten re cur rence and risk of anal in con ti nence/5/. Though there are a great va ri ety of dif fer ent op er a tivemeth ods for the high (com plex) fis tula, now a days the li ga -tion method with elas tic seton is ba sic and most com -mon/2,6,7/.AIMThe aim of this ret ro spec tive study is to an a lyze the fre -quency of trans- and extrasphincteric ARF, their dis tri bu -tion by sex, age, as well as the ap pli ca tion of the li ga tionmethod as one stage rad i cal op er a tive treat ment and fi nallyas sess the rad i cal treat ment in terms of short and long termre sults and re cur rence. MATERIALS AND METHODSFor a ten years pe riod /2000 – 2010/, 152 pa tients with high trans- and extrasphincteric ARF have been op er ated in ourclinic. As ARF have cryptoglandular or i gin, spe cific fis tulain Crohn’s dis ease, tu ber cu lo sis, actinomycosis is ex cluded from the study. Men were 123 (80.92%), women – 29(19.08%), with a ra tio 4.2: 1. Age var ied from 21 to 74years. Extrasphincteric fis tula was 70 (46.05%), whiletranssphincteric were 82 (53.95%). Re cur rent ARF havebeen ob served in 18 (11.84%) pa tients. Al pa tients wereop er ated in gynecological po si tion, un der in tra ve nous orepidural an es the sia. Af ter ex am i na tion of the fis tula chan -nel with a probe we de fine the lo cal iza tion of the fis tulachan nel ac cord ing to sphincter com plex. We start with el -lipse skin in ci sion in clud ing the fis tula open ing and ad -vanc ing cir cumfer entially ex cise the en tire fis tula chan nelto the sphincter. Af ter cu ret tage of the fis tula chan nel at thesphincter, we ap ply the elas tic Seton li ga tion pass ingthrough, or above the sphincters. The seton is tres passedthrough the in ter nal open ing and we tight it mod er ately.This method of grad ual tight en ing and sec tion ing of thesphincter mus cles due to ischemia and cicatrisation pre -vents in con ti nence and keeps sphincter func tion al ity. 399Scripta Scientifica Medica, 2011; vol. 43 (5) Copyright © Med i cal Uni ver sity, VarnaMean hos pi tal stay is 12.71 days, with a mean pe riod ofwound heal ing of 41.53 days. Pa tients were fol lowed uppost op er a tively on 1 month, 3 months, 6 months and ev ery12 months there af ter. Re cur rences were reg is tered in thefirst 6 months in 8 pa tients (5.26%) - 6 in the first 3 monthsand 2 – up to the 6 month. Of them 7 pa tients were op er ated suc cess fully in our clinic, while the 8th pa tient was cured af -ter 3 con sec u tive op er a tions. All pa tients were care fully ex -am ined by in spec tion, pal pa tion of the perianal re gion, dig -i tal rec tal ex am i na tion, anoscopy, prob ing, rectoscopy andsome times fistulography and endoanal sonography.RESULTS In 140 pa tients (92.11%) ARF are re sult of pre vi ousanorectal ab scess, while the other 12 болни (7.89%) lacksclear in for ma tion about the or i gin. In 43 pa tients (28.29%)there has been spon ta ne ously opened ARA, af ter whichthey have been op er ated, while 17 oth ers (11, 18%) alsoopened spon ta ne ously, but were not treated un til fis tula se -cre tion ap peared.In the post op er a tive pe riod we per formed staged and con -trolled tight en ing of the seton lig a ture. Post op er a tive care is of great im por tance for rad i cal cure of the ARF pa tients.The daily baths and an ti sep tic ban dages with Jodine lin i -ment are im por tant fac tor for good treat ment of the woundsur face, where heal ing goes from depth to the sur face. An -other main step is the pe ri odic tight en ing of the elas tic li ga -tion ev ery 4 days. It usu ally takes 2 or 3 times of tight en ingun til lig a ture fells down (mean 3.28 days). The to tal meanpe riod for cut ting the elas tic li ga tion is 10.23 days, whilemean time for wound heal ing is 41.57 days.DISCUSSIONThe cor ner stone in the rad i cal op er a tive treat ment of ARFwith elas tic Seton is the ex act and pre cise iden ti fi ca tion ofthe to pog ra phy and anat omy of the fis tula chan nel from itsbe gin ning to its end/8/. The im ple men ta tion of the li ga tion method de pends mainly on the type, lo cal iza tion, length and com plex ity of the fis -tula, pres ence of ad di tional ab scess cav i ties, in fil trates, andsec ond ary chan nels, stage of de vel op ment, num ber andkind of pre vi ous pro ce dures per formed/8,9/. Pre op er a tively we al ways clar ify the lo cal iza tion, num berand di rec tion of the fis tula chan nel, and most im por tantlythe place of the in ter nal open ing ac cord ing to the rule ofGoodsall. The chronic in flam ma tion around the fis tulachan nel leads to fi bro sis, which is al ways man i fested at pal -pa tion in the pararectal tis sues. Very ap pro pri ate for the ex -act lo cal iza tion is the bidigital pal pa tion - right in dex fin gerprob ing the anal chan nel and left in dex fin ger pal pat ing theex ter nal perianal fi brous thick en ing, start ing from the outerfis tula open ing. In the re gion of the in ter nal open ing wepal pate a hard nod ule cor re spond ing to the fib rously de gen -er ated anal crypt, from which the fi brous fis tula chan nelstarts. Pre op er a tively we al ways as sess the anal sphincterfunc tion, es pe cially in re cur rent and long last ing ARF. Theprob ing through the ex ter nal open ing de fines the di rec tionof the fis tula chan nel, per form ing it care fully, non trau matic un der dig i tal con trol in the anal chan nel. The best probe isthis of plas tic metal, with a ball point tip al low ing twist ingalong the chan nel. We fol low the non traumatizing andnone forced pas sage of the probe through out the wholechan nel till its in ter nal open ing in the crypts of Mor gan. Indif fi cult cases we use hy dro gen per ox ide and meth y leneblue for the iden ti fi ca tion of the in ter nal open ing. We ex -cise cir cumfer entially and to tally the fis tula chan nel upalong the in stilled probe to the ex ter nal anal sphincter andthen per form cu ret tage be low the sphincter to wards the in -ter nal open ing and place the elas tic seton. Some times along the fis tula chan nel we can ob serve tis sue thick en ing, ab -scess cav i ties and bruises as a con se quence of pre vi ous ex -ac er ba tions and in ci sions. In cases of de layed treat ment for -ma tion of new fis tula and open ings fol lows, lead ing tohorse shoe fistulae. The ap plied seton li ga tion grad u allycuts the sphincter mus cles, thus the in ter nal open ing mi -grat ing in dis tal di rec tion, un til its liq ui da tion. Be yond thecut ting li ga tion the wound is filled with gran u la tion tis sue,with fol low ing ci ca trix for ma tion, fix ing the cut sphincterfi bers. The elim i na tion of the in ter nal open ing and the heal -ing of the perianal wound go con sec u tively and syn chro -nously to gether with the fell down of the lig a ture. Thisgran u lat ing wound al lows good drain age and nor mal heal -ing. The sur gi cal tac tics in the li ga tion method of treat ment ofARF is de ter mined by three ba sic prin ci ples:• maximum excision of the fistula channel to thesphincter• exact revision and drainage of the present abscesscavities.• liquidation of the internal fistula opening • The sound fulfillment of all these steps is of greatimportance, especially the precise identification of theinternal opening. • Great disadvantage in the operative treatment of ARF is that even if a small fistula segment is overlooked andleft, recurrence follows. We did not per form any an ti bi otic ther apy perioperatively.The usual pre op er a tive prep a ra tion in cluded lax a tives andrarely en ema. We used in tra ve nous or epidural an es the sia.Most com mon fail ure in anorectal fis tula sur gery co mesalong with re cur rence and anal sphincter dys func tion. Post -op er a tive anal con ti nence de pends on the type of ARF,num ber of post op er a tive tight en ing of the li ga tion, pres ence of ad di tional fis tula chan nels and wide ness of the woundsur face/10/. The main rea sons for re cur rence are lack com -plete ver i fi ca tion of the whole fis tula chan nel, false iden ti fi -ca tion of the in ter nal open ing, over looked or mis treatedside fis tula chan nels, not rad i cal op er a tive treat ment andpost op er a tive neg li gence/10,11/.400CONCLUSIONThe main rea son for the oc cur rence of ARF is the late re fer -ral of pa tients and not rad i cal treat ment. Com plete cure ofARF de pends mainly on the pre cise iden ti fi ca tion anderradication of the in ter nal fis tula open ing, which is an in -flam ma tory pro cess en try. Treat ment of the high ARF re -quires pro fes sional ex pe ri ence and is best per formed inspe cial ized coloproctologycal cen ters. The seton li ga tionmethod has the ad van tages of easy to per form in one stagewith less ex penses, low re cur rence and pos si bil ity for ap pli -ca tion in com plex fistulae. Dis ad van tages of the method are long-term treat ment and risk of anal in con ti nence.REFFERENCES1. Durdun V, Perek A, Kapan M, et al: Par tialfistulotomy and mod i fied cut ting Seton pro ce dure inthe treat ment of high extrasphincteric perianalfistulae. Di gest Surg 19:56-58, 20022. Dziki A, Bartos M: Seton treat ment of anal fis tula:Ex pe ri ence with a new mod i fi ca tion. Eur J Surg164:543-548, 19983. Hammond TM, Knowles CH, Porrett T, et al: Thesnug Seton: Short and me dium term re sults of slowfistulotomy for id io pathic anal fistulae. Colorectal Dis 8:328-337, 20064. Gurer A, Ozlem N, Gokakin AK, et al: A novel ma te -rial in Seton treat ment of fis tula-in-ano. Am J Surg193:794-796, 20075. Graf W, Pahlman L, Ejerblad S, et al: Func tional re -sults af ter Seton treat ment of high transsphinctericanal fis tu las. Eur J Surg 161:289-291, 19956. Isbister WH, Al Sanea N: The cut ting Seton: Anexpererience at King Faisal Spe cial ist Hos pi tal. DisCo lon Rec tum 44:722-727, 20017. McCourtney JS, Finlay IG, McCourtney JS, et al:Cut ting Seton with out pre lim i nary in ter nalsphincterotomy in man age ment of com plex high fis -tula-in-ano. Dis Co lon Rec tum 39:55-58, 19968. McCourtney JS, Finlay IG, McCourtney JS, et al:Setons in the sur gi cal man age ment of fis tula in ano.Br J Surg 82:448-452, 19959. Theerapol A, So BY, Ngoi SS, et al: Rou tine use ofsetons for the treat ment of anal fistulae. Sin ga poreMed J 43:305-307, 200210. Vitansev C, Alabaz O, Tekin A, et al: A new Setontype for the treat ment of anal fis tula. Dig Dis Sci 52:1920-1923, 200711. Wil liams JG, MacLeod CA, Rothenberger DA, et al:Seton treat ment of high anal fistulae. Br J Surg78:1159-1161, 1991401Scripta Scientifica Medica, 2011; vol. 43 (5) Copyright © Med i cal Uni ver sity, Varna

Elastic seton procedure for surgical treatment of anorectal fistulas

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Elastic seton procedure for surgical treatment of anorectal fistulas

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