Seton's Placement

Seton placement

Seton Placement: This is a surgical method to reverse a fistula most frequently an anal (perianal) fistula - a tunnel inside the rectum or anus, which develops between the luminal lining of the rectum or anus and its skin. 

What Is a Seton?

A Seton is a loop of elastic material (e.g. surgical thread, rubber band, silicone or nylon cord) which is passed through the fistula tract and tied up at both ends, creating a continuous loop. 

Why Seton Placement Is Done?

The main goals are to:

• Waste constant drainage of the fistula tract to avoid abscess and persistent infection. 
• Encourage regulated healing and fibrosis in complex fistulas. 
• Minimize the chance of major incontinence by limiting the amount of anal sphincter muscle cut especially in complex or high fistulas. 
• Prepare the tract to a subsequent definitive surgery (in staged operations). 
• It is especially practical in cases where a fistula has a considerable size of the sphincter muscle, fistula has recurred, or in patients with other diseases such as Crohn.

Types of Setons

• Loose/Draining Seton- Removed comparatively loose to permit continuous drainage without incision of tissue. 
• Cutting/Tight Seton – This Seton is placed tight and cut down over time to slowly cut tissue whilst encouraging scar formation; when controlled cutting is a part of the healing process.

Seton placement anal fistula

A Seton is a flexible loop (silicone, rubber, nylon or surgical thread) that is inserted through the fistula tract, entering the external aperture and leaving the internal one in the anal canal. The final ends are looped together.

Types of Setons

Loose (draining) Seton

• Most commonly used
• Allows continuous drainage
• It is able to remain weeks to months in one place.
• This is often accompanied by other operations such as LIFT, fistulotomy or advancement flap.

Cutting (tight) Seton

• Slowly clenched with time.
• It carves slowly in the fistula and heals behind it.
• Selectively used only because more uncomfortable and at risk of incontinence.

Seton placement procedure

The following is a straightforward stepwise description of the Seton placement procedure to an anal fistula:

Pre-operative preparation

• Rudimentary blood screenings and health to undergo anaesthesia.
• Bowel magnification is typically unnecessary.
• You will be required to fast 6-8 hours.
• Antibiotics can be administered prior to surgery.

Anaesthesia

• Performed with either spinal anaesthesia or general anaesthesia.
• The procedure will not be painful.

Positioning

• Lithotomy or prone jack-knife position of the patient.
• This provides a good access to the anal area.

Detection of the fistula tract

Surgeon locates:

• External opening (on the skin)
• Internal opening (throughout the anal canal)
• The tract can be mapped by the use of a probe/ dye (methylene blue/hydrogen peroxide).

Passing the Seton

• Elastic, supple substance (silicone loop, rubber band, nylon thread, or silk) is:
• Absorbed via the fistula tract.
• Coming in through the outside door.
• Getting out by the inside door.

Securing the Seton

• The two extremes are also connected loosely (most common).
• This is a loop that is located inside the fistula tract.

The Seton is positioned so it:

• Allows continuous drainage
• Does not incise sphincter muscles (except when applied as a cutting Seton)

Final inspection

• Bleeding is checked
• Area is cleaned
• There are no stitches that are typically required.

Duration of procedure

• 30–60 minutes
• Mostly a day-care surgery

After the procedure

• A little pain or discomfort is expected.
• Constant discharge should be anticipated (a good sign).
• Home is usually on the same day.
• Sitz baths and painkillers are recommended.

Seton placement recovery

Seton Placement Recovery: Expectancy

Immediate recovery (Day 0–3)

Normal

• Mild or moderate pain or burning.
• Constant spurt (pus/blood-stained fluid)
• Pain of a rubber band or a string around the anus.

What helps:

• Prescription pain drugs.
• Sitz baths (warm water) 2-3 times/day and post bowel movements.
• Absorbent soft gauze or pads.
• The majority of patients are discharged in the same day.

Short-term recovery (Week 1–2)

Normal

• Continuous drainage (this is good and should be)
• Pain when sitting or passing a bowel.
• Mild itching or irritation

Care tips

• Keep the area clean and dry
• Change pads frequently
• Avoid constipation:
• High-fiber diet
• Plenty of fluids
• Stool softeners as prescribed.
• Never strain when passing stools.
• One can resume light activities in 2-3 days.

Medium-term recovery (Weeks 3–6)

What improves?

• Pain gradually reduces
• Discharge reduces but not necessarily ceases.
• You become accustomed to the presence of the Seton.

Lifestyle

• Fine walking, sitting and housekeeping.
• Do not lift heavy things, or ride a bicycle, or sit down a long time in an uncomfortable position.
• Pain is the factor that enables one to resume sexual life again (advice of the doctor counts).

Long-term outcome (After 6 weeks)

• Seton can stay up to weeks or months.

Purpose is to:

• Keep fistula draining
• Let inflammation settle
• Ready the definite surgery (LIFTs, fistulotomy, flap, laser)
• There are instances when a loose Seton can be retained over a long period of time in case the symptoms are under control.

Pain & bowel movement care

• In most cases, the pain is always acute during the initial few days and then gets better.
• First bowel movement can be painful though not extreme.
• The occurrence of pain is greatly diminished when a sitz bath follows bowel movement.

Diet during recovery

• Low-fiber foods 
• Fluid intake is adequate. 
• Oily foods and spicy foods should be avoided in case they make the discomfort worse.
• Every effort should be made to avoid constipation.

Seton placement complications

The following is the list of complications following Seton surgery to treat an anal fistula:

Common & Usually Mild

• Pain or discomfort
• Continuous discharge
• Local irritation or itching

Less Common Complications

• Infection
• Bleeding
• Seton displacement or falling out
• Skin excoriation

Rare but Important Complications

• Anal incontinence
• Severe pain
• Delayed healing or non-healing fistula
• Allergic reaction

Best hospital for seton placement India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Seton placement is a safe, effective and sphincter-sparing therapy of anal fistula, particularly in complex or high fistula in which direct resection of tract may lead to incontinence. It is an effective way of infection control, inflammation reduction, and recurrence prevention of abscesses by means of continuous drainage. Even though minor discomfort and discharge are normal in the course of recovery, severe complications are not common, especially where loose (draining) Setons are involved. Seton placement may be a temporizing measure, to prepare the fistula to permanent procedures, like fistulotomy, LIFT, advancement flap, or laser closure after the healing conditions are better. When the postoperative care is good and closely followed, majority of the patients have good symptom control, maintained continence and improved quality of life.

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FAQ

1. Is Seton placement a permanent cure for Fistula?

• No, not always. Seton placement is often just the initial part of the treatment, with a complete procedure like fistulotomy, LIFT, advancement flap, or laser closure following. Loose Setons may also alleviate symptoms over long periods.

2. Does Seton placement hurt?

• After surgery, mild to moderate pain may occur during the first two or three days and can be usually being controlled with medication and sitz baths. Long-term pain is rare, in particular with loose Setons.

3. For how long does the Seton remain?

• Depending on type of fistula and healing process. Some patients choose to retain them for longer, if the symptoms are well managed.

4. Are there chances of getting risks?

• Loose Setons have a very minimal risk. Cutting Setons have a greater risk and they are used selectively with a lot of supervision.

5. What to do after removing the Seton?

• Depending on healing, your surgeon may perform the definitive fistula surgery or wait to see if the fistula is healed enough without further surgery.

6. Is it possible that the Seton falls off?

• Yes but it is unusual event. If it does, you should report to your surgeon to be seen and possibly replaced.