Use of Penrose Drains To Treat Certain Anal Fistulas: A Primary Operative Seton
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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The Use of Setons in Fistula-in-Ano
2009, Seminars in Colon and Rectal SurgeryCitation 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
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2022, Tropical DoctorA new seton tightening method for anal fistula treatment: Sailor’s knot
2021, Annali Italiani di Chirurgia