Seton's Tightening

Seton tightening

Seton tightening is a gradual procedure that involves a tool known as a cutting Seton in treating an anal fistula to ensure the anal sphincter is not damaged.

What does tightening mean?

A cutting Seton (typically a surgical thread, rubber band or silicone loop) is inserted through the fistula tract. With time, it is periodically constricted thus gradually slicing through the tissue as the tract closes behind it.

Why is it done?

• To excise the fistula and leave not one big incision.
• To lower the potential risk of incontinence as contrasted with one-stage fistulotomy.
• Applicable in high or complicated fistulas that involve sphincter muscle.

How often is it tightened?

• Typically every 2–4 weeks
• Conducted in the outpatient clinic.
• The procedure normally requires no anaesthesia or locally applied anaesthesia.
• The sessions are only a matter of minutes.

Seton tightening procedure

Seton tightening is a short term outpatient operation performed to patients who have a cutting Seton on an anal fistula.

Before the procedure

• There is no fasting that is usually necessary.

You may be advised to:

• Prepare a painkiller in advance which is mild in nature.
• Prior to visit empty bowels.

The area is examined to check:

• Healing progress
• Infection or over inflammatory symptoms.

Positioning

• You will be in a left lateral or lithotomy position.
• The perineal zone is wiped with an antiseptic.

Anaesthesia (if needed)

• There are numerous tightenings that are performed without anaesthesia.

Some surgeons use:

• Topical anaesthetic gel, or
• In case of high sensitivity, local anaesthesia injection.

Actual tightening

The surgeon:

• Identifies the Seton knot
• Use gentle pulling in order to tighten the loop.
• Unloosens slack and knot is re-tied.
• The constriction is slight and moderate--never excessive.
• This process normally lasts 2-5 minutes.

After tightening

• Slight hemorrhage or pain can be experienced.
• You sleep a little and are in a position to be home the same day.
• Neither stitches nor dressings are required.

Frequency of tightening

• The procedure is usually carried out at every 2-4 weeks.

Continued until:

• The Seton cuts slowly through the tract, or
• The fistula is fully healed.

Post-procedure care

• Warm sitz baths 2–3 times daily
• Prescribed Oral painkillers.
• Stool softener and high-fiber diet.
• Do not strain, and no longer than 24-48 hours. 

Seton tightening surgery

Tightening phase comes after the Seton placement surgery has been performed initially. The surgeon tapers Seton during every session to gradually cut the tract of the fistula and the sphincter muscle behind, so that it heals, and the bowel control is not lost.

Surgical procedure in stages

Primary surgery: Seton repair

• Performed with spinal or general anaesthesia.
• Fistula tract is identified
• The tract is passed through a cutting Seton (silk, rubber, silicone).
• Ends are tied loosely
• Discharge of patient within a day or the next day.
• Recovery: 2-3 weeks prior to the onset of tightening.

Seton tightening procedures (minor surgical procedures)

• Performed in OPD or minor OT
• Patient in comfortable position.
• Space wiped with antiseptic.
• In case of necessity, local anaesthesia can be administered.
• Seton loop is re-tied and made tighter.
• Takes 5–10 minutes
• No stitches
• Same-day discharge

Number of tightening sessions

• Usually 3–8 sessions
• Interval: every 2 to 4 weeks
• Duration of treatment: 6 to 12 weeks (may be extended in complex cases) 

Seton tightening recovery

The rate of healing after Seton tightening is usually faster and less difficult than the surgery that was initially performed to tighten the Seton. It can be easily treated by home care with most individuals.

(First 24-72 hours) Immediate Recovery

What’s normal?

• Moderate to slight pain or discomfort.
• Tight or pulling sensation
• Light leukemia or discharge.
• Sexual pain when sitting or bowel movements.

Pain control

• Analgesic or paracetamol which can be prescribed.
• Warm sitz bath 2-3 times a day (10-15 minutes) 
• Prevent constipation (highly significant)

Short-term recovery (3–7 days)

• Pain gradually reduces
• Light activities are comfortable, and walking.
• Discharge decreases
• The vast majority of the patients are back at work within 1-2 days.

Between tightening sessions (2-4 weeks)

• Seton goes on cutting through slowly.
• Mild discharge is common
• Maintain strict hygiene
• Maintain big fiber and hydration.

Bowel movement care

• Use softeners of stool as recommended.
• Do not strain
• Wash using either water or wet wipes (do not use dry toilet paper)

Activity guidelines

• Walking: encouraged
• Normal daily activities: 24-48 hours postpartum.
• Lifting of heavy weight, bicycling, sitting continuously: should not be done within a few days.
• Vigorous exercise: do not do during 3-5 days.

Diet during recovery

• Whole grains, vegetables 
• Plenty of fluids
• First avoid spicy and oily food.
• Take no alcohol until cured.

Seton tightening complications

Seton tightening is usually a safe, effective surgery particularly in complicated anal fistula- however, as with any surgery; Seton tightening may be associated with complications. Majority of them are mild and manageable when they are identified early.

Common complications

• Pain and discomfort
• Local irritation and skin soreness
• Discharge or mild bleeding

Less common complications

• Infection
• Delayed healing
• Seton slippage or breakage

Rare but important complications

• Incontinence (loss of bowel control)
• Fistula recurrence

Best hospital for seton tightening India

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

Conclusion

Seton tightening is a safe, gradual, non-excising, and sphincter-sparing technique in treating complex anal fistulas. The Seton is tightened in phases enabling the fistula to heal gradually with reduced chances of incontinence. Though it may have mild pain, discharge, or irritation, there are no severe complications in case of a carefully done procedure and the aftercare. A smooth recovery is achieved by ensuring that there is follow-up regularly, good hygiene, pain management, and prevention of constipation. Seton tightening is a good long term and high success rate procedure when performed with expert supervision hence making it a desirable choice in patients with high or recurring fistulas.

Seton tightening India GetWellGo

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FAQ

1. Is it very painful to tighten a Seton? 

• Tightening of the Seton causes mild to moderate pain, which lasts usually 1–3 days after each session. The pain is usually well controlled with analgesics and warm sitz baths. 

2. Can I ask what kind of Seton you have?

• Discomfort is minor and is usually experienced 1 to 3 days after each session of Seton tightening. Well controlled with analgesics and warm sitzbaths.

3. Will Seton tightening impact bowel control?

• There is rare incidence of long term incontinence when tightening is gradual & under supervision. The patients may experience transient urgency to evacuate gas.

4. Can the Seton come out or break?

• It can be dislodged or broken off at times. In the event this occurs contact your surgeon- do not try to remove it yourself.

5. When does Seton tightening end?

• Tightening is stopped when the Seton has completely cut through or the fistula has healed, as determined by your surgeon.

6. How successful is the Seton tightening?

• The success rates are usually more like 80-90% particularly for complex fistulas where follow up is frequent.

7. Can the fistula come back after Seton treatment?

• Recurrence is possible but is rare, especially if the entire course of treatment is completed.

8. Is Seton tightening better than fistulotomy?

• For high or complex fistulas, yes — because it provides better protection of sphincter muscles. Low fistulas are more likely to be treated fistulotomy.