Use of Penrose Drains To Treat Certain Anal Fistulas: A Primary Operative Seton

doi:10.1016/S0025-6196(12)62413-6

Mayo Clinic Proceedings

Volume 59, Issue 9, September 1984, Pages 613-617

https://doi.org/10.1016/S0025-6196(12)62413-6 Get rights and content

In 20 selected patients with a complex anal fistula, a seton consisting of a 1/4- to 5/8-inch Penrose drain was passed through the anal fistulous tract and then sutured to maintain tension. This elastic seton not only provides drainage of the fistulous abscess but also, by pressure necrosis of the enclosed sphincter muscle, “cuts through” the muscle and accomplishes primary fistulotomy or, when placed without tension, serves as a marker for later fistulotomy. All 20 patients had a good result. One patient complained of occasional leakage of mucus. Two others were periodically incontinent of loose stools but were socially continent and employable. Use of a seton should be considered in patients with complex fistulas that involve the puborectal muscle.

Section snippets

PATHOGENESIS OF A FISTULA

In 1936, Miles¹ wrote, “Every fistula is preceded by an abscess and the main track of the fistula is the contracted but unobliterated original abscess cavity.” Even more simply stated, a fistula in ano is the chronic phase of an acute abscess. Eisenhammer² termed the evolution of the process a fistulous abscess.

The intramuscular glands in the crypts of the dentate line often penetrate the internal sphincter muscle of the anus and terminate in the areolar tissue between that smooth muscle and

MATERIAL AND METHODS

Records of patients treated by the primary operative seton from 1976 through 1981 were reviewed. This time interval was used to provide a period of adequate follow-up to determine the continence of patients, their satisfaction with the results, and the possible recurrence of the inflammatory process.

The indications for use of a seton in this study were as follows:

1.
The presence of a complex fistula that involved the puborectal muscle
2.
Distortion of the anorectal anatomy to such a degree that

OPERATIVE TECHNIQUE

With use of regional anesthesia (caudal), a small malleable probe is gently rotated along the track to determine the limits of the fistula and its relationship to the puborectal muscle (Fig. 2 a). Palpation alone will not accurately reveal the extent of involvement. Careful dissection of the tissues overlying the probe to demonstrate the muscle mass that constitutes the roof of the fistulous “tunnel” is necessary.

After assessment of the situation, the seton (a 1/4- to 5/8-inch Penrose drain) is

RESULTS

The study group consisted of a personal series of 20 patients who had been followed up for 2 years or longer. During the study period (1976 through 1981), an additional 159 patients underwent a standard fistula operation, which was performed by the author. More than half of the seton-managed patients underwent treatment during the last 2 years of the 6-year review period. Four of the fistulas originated in processes extrinsic to the ano-rectum (two presacral dermoids, one fistula associated

DISCUSSION

Many classifications of anal fistulas have been proposed, but convenient categorization is often impossible at the time of operation. As Lilius⁴ maintained, “The different parts of the sphincter are difficult to identify at operation in normal conditions, to say nothing of when they are infiltrated by an inflammatory process.” Parks and Stitz,⁵ whose classification has been used by many colorectal surgeons, stated, “In operative assessment of a fistula, it must be remembered that the fibrosis

CONCLUSION

In 20 patients, use of a Penrose drain seton for treatment of fistula in ano yielded good results. A seton can provide drainage of a fistula whether it is used as a primary tool to transect the muscular roof of the fistula or as a marker for a later surgical procedure. Fibrosis of the enclosed sphincter muscle is promoted; thus, undue retraction at the time of fistulotomy is prevented. Anal contour is preserved because separation of the edges of the “setonized” wound is minimal.

Use of a primary

ADDENDUM

Since the conclusion of this study, an additional 18 patients have had the application of an operative seton, including 2 patients who have had an ileoanal anastomosis. To date, all have reported that the continence that existed before the use of the elastic seton has not been compromised. A review of this group will be presented in the future.

ACKNOWLEDGMENT

I wish to thank Robert W. Beart, Jr., M.D., for his suggestions and guidance in the preparation of this article.

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There are more references available in the full text version of this article.

Cited by (43)

The Use of Setons in Fistula-in-Ano
2009, Seminars in Colon and Rectal Surgery
Citation Excerpt :
Minor and major incontinence rates with internal sphincterotomy division of 69% and 19%15 and 5 of 10 (50%) and 2 of 10 (20%)28 have been reported and these are higher than most series where the internal sphincter is cut through by the seton more gradually. There are numerous reported types of seton material used including silk, nylon, stainless steel thread, and Mersiline sutures,4,17,19,20 Silastic slings and vessel loops,23,28 rubber bands,10,29 Penrose drains,6 surgical gloves,21 and various other nonbraided and braided sutures. There have been several articles that document the use of alternative seton material including a self-locking cable tie30,31 or tightening the seton using Baron bands.32
Setons in the treatment of fistula-in-ano have been used for thousands of years. Although there are few high-quality prospective trials, there are numerous retrospective series documenting high cure rates of more than 90% with cutting setons or two stage seton fistulotomy. Both techniques, however, result in a variable rate of incontinence, higher with two stage seton fistulotomy where the internal anal sphincter is routinely divided. Incontinence rates for slow cutting setons are 10%-20% for minor incontinence with rates of 0%-10% for major incontinence; compared to rates of more than 35% and as high as 70% with the two-stage technique. Loose draining setons have an important role the management of Crohn's disease and can result in good palliation with minimal risk of deterioration of bowel control.
Cutting seton for complex anal fistulas
2008, Surgeon
Purpose: A standardised protocol for performing a cutting seton has not been well described in the existing literature. The aim of this study was to examine our experience of treatment of complex anal fistulas by cutting seton over 15 years in our hospital, detailing surgical technique, results and complications. Methods: Between 1990 and 2004, 112 patients with complex anal fistulas were treated by applying cutting setons in our hospital. The elastic band from a surgical glove was used as the seton material. The seton was re-tightened for the first time in the second week after the initial operation and then at weekly intervals. Results: There were 98 male and 14 female patients, with a median age of 43 years. Eighty-four patients had trans-sphincteric or suprasphincteric fistulas, and 28 patients had extrasphincteric fistulas. The mean operative time was 42 minutes. The mean number of seton ties was 3.3 times. The mean duration with the seton in place was 28.7 days. The mean time of the wound healing was 9.3 weeks. Median period of follow-up was 38.6 months. Recurrence was found in one patient (0.9%). Twenty-seven patients (24.1%) were noted with continence disorders, including gas incontinence in 21 patients (18.6%) and liquid stool incontinence in 6 patients (5.4%). There were no incidents of solid stool incontinence. Conclusions: Using the elastic band from a surgical glove as a seton with repeated tightening at weekly intervals is safe and effective, with shorter duration of wound recovery, low recurrence and less continence disorders.
A novel material in seton treatment of fistula-in-ano
2007, American Journal of Surgery
Fistula-in-ano is a common surgical problem. Various materials have been used to perform the seton technique in the treatment of fistula-in-ano. In this study, a novel material, a self-locking cable tie, was used regardless of the fistula type. Seventeen consecutive patients with anal fistula underwent surgery with the cutting seton technique using the novel material. Nine patients had high fistulas. The average tightening was 3.18, the mean fall-out time was 17.41 days, and the mean follow-up period was 8.2 months. No recurrences or incontinence were recorded. There are statistically significant differences between superficial and high fistula cases regarding the number of setons tightening, seton fall-out time, and complete healing time. The novel material presented here has some advantages: it is cheap, easily available, and easily applied, moreover, a gradual tightening can be performed. We think this novel material is a good choice in the treatment of fistula-in-ano.
Comparing the efficacy and safety of different thread-drawing surgery method for treating high complex anal fistula: a systematic review and network meta-analysis
2023, International Journal of Colorectal Disease
Seton in high anal fistula
2022, Tropical Doctor
A new seton tightening method for anal fistula treatment: Sailor’s knot
2021, Annali Italiani di Chirurgia

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Use of Penrose Drains To Treat Certain Anal Fistulas: A Primary Operative Seton

Section snippets

PATHOGENESIS OF A FISTULA

MATERIAL AND METHODS

OPERATIVE TECHNIQUE

RESULTS

DISCUSSION

CONCLUSION

ADDENDUM

ACKNOWLEDGMENT

Clin Gastroenterol

Ano-rectal fistulae

Postgrad Med J

Advance of ano-rectal surgery with special reference to ambulatory treatment

S Afr Med J

Abscesses and sinuses in the perianal region: differential diagnosis and treatment

Texas State J Med

Fistula-in-ano: an investigation of human foetal anal ducts and intramuscular glands and a clinical study of 150 patients

Acta Chir Scand [Suppl]

The treatment of high fistula-in-ano

Dis Colon Rectum

The orthodox conception of fistula-in-ano and its treatment

Proc R Soc Med