Long‐term outcomes after seton placement for perianal fistulas with and without Crohn’s disease

Abstract

Aim Perianal sepsis in Crohn's disease (CD) fistulas is managed with antibiotics and surgical drainage; a noncutting seton is used for an identified transsphincteric fistula tract. The optimal management following seton placement for initial control of perianal sepsis remains to be determined. Our main aim was to assess the success rates of curative surgery, seton removal or long‐term indwelling seton in patients with and without CD. Method This was a retrospective cohort of consecutive patients with a perianal fistula treated with a noncutting seton between 2010 and 2019, including 83 CD patients and 94 patients without CD. Initial control of symptomatic perianal infection with a seton and subsequent healing and reintervention rates were compared between the three postseton management strategies. Results A total of 177 patients, 61% male and 83.1% with complex fistulas, were followed for a median of 23 months (interquartile range 11–40 months). Immunomodulatory treatment was used in 90.4% of CD patients after seton placement. Good initial control of perianal infection was achieved with a seton in CD and non‐CD patients, at 92.9% and 96.7%, respectively (p = 0.11). Overall fistula healing or control for CD and non‐CD patients was, respectively, 64% and 86% (p = 0.1) after curative surgery, 49% and 71% after seton removal (p = 0.21) and 58% and 50% with long‐term seton placement (p = 0.72). Overall reintervention for recurrence was 83% in CD versus 53.1% in non‐CD patients during the follow‐up period (p = 0.002). Conclusion Definitive surgery was possible in only a minority of CD patients. Long‐term seton management was an effective option in patients with CD with acceptable improvement and recurrence rates.

Evaluation surgical strategies in perianal fistulas treatment: Efficacy draining seton compared to other surgical approaches; a case‐control study

“…It has been found that CD patients with perianal fistula can considerably benefit from long-term management with seton. 15 As a result of our study, 94.4% of patients in the seton group experienced an improvement in their fistula; however, no significant difference was recorded between the two groups. According to Rosen et al investigation of 121 patients (80 men) suffering from intra-sphincteric fistula, 98% of patients achieved complete fistula resolving without fecal incontinence under cutting seton treatment.…”

“…To reduce fecal incontinence in perianal fistula cases, seton insertion can be used as a conventional therapeutic option to prepare the fistula for other procedures. It has been found that CD patients with perianal fistula can considerably benefit from long‐term management with seton 15 …”

“…It has been found that CD patients with perianal fistula can considerably benefit from long‐term management with seton. 15 …”

“…Besides, the seton technique is a more effective alternative than a single‐stage fistulotomy in preserving functionality through the slow division of the sphincter muscles along with the low risk of developing incontinence 2,14 . Moreover, based on the Motamedi et al 15 investigation, long‐term seton management was a practical option in CD patients due to proper healing and recurrence rates. Additionally, CD patients under regular follow‐up with symptomatic anal fistula can benefit from ambulatory exploration of the anal canal and rectum (outpatient exploration) to reduce waiting times for surgical exploration 16 .…”

Non-Crohn's complex and multirelapsed perianal fistulas treated with sphincter sparing surgical procedures and adjuvant adipose tissue injection

“…Surgery, the only curative treatment, obtained suboptimal results with high percentages of persistence or recurrence and a high risk of postoperative fecal incontinence [1,3]. The results are even worse in previously operated patients [1,3], and, in some cases, palliative treatment with long-term setons is considered [4,5].…”