The use of the loose seton technique as a definitive treatment for recurrent and persistent high trans-sphincteric anal fistulas: A long-term outcome

Background: The loose seton technique (suggested to avoid any external anal division following seton placement, to ensure anal continence) was assessed as the ultimate approach for primary as well as recurrent and persistent anal fistula. Study Design: Between 2000 and 2006, 97 patients were operated for trans-sphincteric anal fistula, 41 patients of whom (42.3%) underwent the loose seton technique. The outcome was assessed periodically at the outpatient colorectal clinic and finally by detailed telephonic questionnaire. Mean age was 45.3 years. Thirty one operations were elective (75.6%). Fifteen (36.5%) patients had concomitant diseases, of whom three suffered from Crohn's disease. Twenty nine patients had previous anal operations. Results: The time from seton placement to its removal ranged from 3 to 7 months. At short-term follow-up, early complications were noted in five patients (bleeding in one and abscess formation in four). Late complications included liquid stool soiling in one patient (2.4%), solid soiling in two, and mucous discharge in three. Post-operative clinical assessment of incontinence according to Cleveland Clinic Incontinence Score revealed scoring ranging from 2 to 6 in those six patients. Neither gross stool nor flatus incontinence was noted. Fistula recurrence (persistence) was noted in eight (19.5%) patients and successfully treated by the same loose seton technique. Conclusions: The loose seton technique for trans-sphincteric anal fistula carries favorable results and can be safely applied while preserving the external sphincter function. We also recommend repeating the technique in case of post-operative fistula recurrence or persistence.