The Use of Seton as a Bridge to Definitive Ligation of the Intersphincteric Fistula Tract Procedure for Fistula-in-ano: A Systematic Review and Meta-analysis

Abstract

Background There is still controversy over the usefulness of seton placement prior to the ligation of the intersphincteric fistula tract (LIFT) surgery in the management of anal fistula. Objective To evaluate the impact of preoperative seton placement on the outcomes of LIFT surgery for the management of fistula-in-ano. Design systematic review and meta-analysis. Data Sources A search was performed on the MEDLINE (PubMed), EMBASE, Scopus, Web of Science, Cochrane Library and Google Scholar databases. Study Selection Original studies without language restriction reporting the primary healing rates with and without seton placement as a bridge to definitive LIFT surgery were included. Intervention The intervention assessed was the LIFT with and without prior seton placement. Main Outcome Measures The main outcome was defined as the primary healing rate with and without the use of seton as a bridge to definitive LIFT surgery. Results Ten studies met the criteria for systematic review, all retrospective, with a pooled study population of 772 patients. There were no significant differences in the percentages of recurrence between patients with and without seton placement (odds ratio [OR] 1.02; 95% confidence interval [CI] 0.73–1.43: p = 0.35). The I2 value was 9%, which shows the homogeneity of the results among the analyzed studies. The 10 included studies demonstrated a weighted average overall recurrence of 38% (interquartile range [IQR] 27–42.7%), recurrence with the use of seton was 40% (IQR 26.6–51.2%), and without its use, the recurrence rate was 51.3% (IQR 31.3–51.3%) Limitations The levels of evidence found in the available literature were relatively fair, as indicated after qualitative evaluation using the Newcastle-Ottawa scale and the Attitude Heading Reference System (AHRS) evidence levels. Conclusions Our meta-analysis suggests that the placement of seton as a bridge treatment prior to LIFT surgery does not significantly improve long-term anal fistula healing outcomes. Ligation of the intersphincteric fistula tract surgery can be performed safely and effectively with no previous seton placement.International prospective register of systematic reviews—PROSPERO registration number: CDR42020149173.

European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula

“…Of this cohort, 93% of patients had a fistulotomy following seton insertion and only 7% reported a healed fistula with a seton alone [92].There is no high-level evidence to support the use of a loose seton on its own with the intention of achieving fistula closure. Placer-Galán et al [93] conducted a systematic review on the outcomes of using a bridging seton prior to performing the LIFT procedure. The meta-analysis included 10 observational studies with a median follow-up of 12 months.…”

“…Placer‐Galán et al. [93] conducted a systematic review on the outcomes of using a bridging seton prior to performing the LIFT procedure. The meta‐analysis included 10 observational studies with a median follow‐up of 12 months.…”

“…did not find a significant difference in the fistula recurrence rate between groups (bridging seton and no bridging seton prior to LIFT). The overall healing rate was 60% in patients with a bridging seton compared with 48.7% in patients without a bridging seton [93]. The main limitations were the retrospective nature of the data and the inclusion of patients with Crohn's perianal fistula.…”

The Efficacy of Porcine Dermal Collagen to Treat Complex Anal Fistulae. Results of a Multicenter Cohort

“…However, although its overall results are 50 to 70% successful, in posteriorly located fistulas, which tend to be more complex, its results are markedly lower, down to 20%. 6 Sphincter section with immediate reconstruction has good results, ranging from 50 to 80% of success, in some studies, but requires healthy muscle section and posterior adequate healing, which can affect continence, so it is not commonly used. 7 The use of plugs, which appeared very promising in early research, has resulted in cure rates of less than 30%, 8 and their use has declined.…”