Multiple Setons as Treatment of Complex or High Fistula in Ano

Purpose: Low Anal fistula is treated by either fistulotomy or fistulectomy. However the treatment of high and complex fistula is difficult and not well defined. The patient usually undergoes tailor made procedure from fistulectomy, Seton insertion, Colonic diversion, Mucosal advancement flap procedure to the newer modalities like fibrin glue or fistula plug. Each procedure has some merits and demerits. We describe the use of Multiple Prolene Setons in cases of high or complex fistula. Methods: From January 2001 to December 2007, 20 consecutive patients with high or complex anal fistulae were treated using Multiple Prolene Setons (MPS). All patients had three setons inserted through each fistulous tract under GA or spinal anaesthesia. One seton was loosely tied to work as cutting seton while remaining two were left loose to work as drainage setons. These setons were further tightened sequentially weeks later. After about 6–8 weeks from insertion of seton, fistulectomy was performed when high/complex fistula were converted to simple fistula. Results: Total twenty (N = 20) patients had MPS treatment. The median age of the patients was 41 (range: 18–70). Of the twenty (N = 20 patients), fourteen (N = 14) patients had primary high fistula while six (N = 6) had recurrent fistula. All fourteen (N = 14) patients with primary high fistula had complete healing of the fistulous tract in 8–12 weeks. Of 6 patients with recurrent fistula, four healed completely in 12 weeks. Two patients had recurrence and were successfully treated again by MPS alone in one while other required diversion colostomy with insertion of MPS. No patient developed faecal incontinence. Almost all patients were satisfied with this treatment. Follow up of the patient was 100% with follow up period of 24–156 weeks. Conclusion: The Multiple Prolene Seton (MPS) method is safe, cheap and effective in the treatment of high and complex type of fistula in ano. Seton cuts not only from above down but also from lateral to medial, thus converting high fistula to simple fistula. It does not cause fecal incontinence, has good cure rate and most patients were satisfied with the treatment.