Pulling Seton: Combination of mechanisms


1 Department of Surgery, Colorectal Research Center, Shiraz, Iran

2 Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran

3 Department of Surgery, Shiraz University of Medical Sciences, Shiraz, IranDepartment of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran

4 Shiraz Blood Transfusion Organization, Shiraz, Iran


Background: Seton-based techniques are among popular methods for treating high type anal fistula. These techniques are categorized to cutting and noncutting regarding their mechanism of action. In this report we are about to describe a new technique, which is a combination of both mechanisms; we call it Pulling Seton.
Materials and Methods: In this technique after determining internal and external orifice of fistula, fistulectomy is done from both ends to the level of external sphincteric muscle. Finally, a remnant of fistula, which remains beneath external sphincteric muscle is excised, and Seton is passed instead of it and tied externally. After the wound heals, patient is asked to pull down the Seton for 3–4 min, 4 times a day. We prospectively enrolled 201 patients with high type anal fistula in this study.
Results: Seton gradually passes through external sphincteric muscle till it is displaced outwards or removed by a surgeon via a small incision. 94% of patients treated by this method accomplished their treatment completely without recurrence. None of the patients developed permanent fecal or gas incontinence. Only 5% of patients developed with recurrence of fistula. Since Seton traction is not permanent in this technique, Seton cuts external sphincter slowly, and minimal rate of incontinence is reported.
Conclusion: Pulling Seton seems to be an efficient way in treating high type anal fistula with minimal rate of recurrence and complications such as incontinence and authors suggest further randomized studies to compare its efficacy with other Seton-based techniques.


Steele SR, Kumar R, Feingold DL, Rafferty JL, Buie WD, Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the management of perianal abscess and fistula-in-ano. Dis Colon Rectum 2011;54:1465-74.  Back to cited text no. 1
Corman ML, Bergamaschi RC, Nicholls RJ, Fazio VW. Corman's Colon and Rectal Surgery. 6th ed. New York Lippincott Williams and Wilkins; 2013.  Back to cited text no. 2
Michalopoulos A, Papadopoulos V, Tziris N, Apostolidis S. Perianal fistulas. Tech Coloproctol 2010;14 Suppl 1:S15-7.  Back to cited text no. 3
Subhas G, Singh Bhullar J, Al-Omari A, Unawane A, Mittal VK, Pearlman R. Setons in the treatment of anal fistula: Review of variations in materials and techniques. Dig Surg 2012;29:292-300.  Back to cited text no. 4
Rickard MJ. Anal abscesses and fistulas. ANZ J Surg 2005;75:64-72.  Back to cited text no. 5
Subhas G, Gupta A, Balaraman S, Mittal VK, Pearlman R. Non-cutting setons for progressive migration of complex fistula tracts: A new spin on an old technique. Int J Colorectal Dis 2011;26:793-8.  Back to cited text no. 6
Cariati A. Fistulotomy or seton in anal fistula: A decisional algorithm. Updates Surg 2013;65:201-5.  Back to cited text no. 7
Vial M, Parés D, Pera M, Grande L. Faecal incontinence after seton treatment for anal fistulae with and without surgical division of internal anal sphincter: A systematic review. Colorectal Dis 2010;12:172-8.  Back to cited text no. 8
Dudukgian H, Abcarian H. Why do we have so much trouble treating anal fistula? World J Gastroenterol 2011;17:3292-6.  Back to cited text no. 9
Lim CH, Shin HK, Kang WH, Park CH, Hong SM, Jeong SK, et al. The use of a staged drainage seton for the treatment of anal fistulae or fistulous abscesses. J Korean Soc Coloproctol 2012;28:309-14.  Back to cited text no. 10
Thornton M, Solomon MJ. Long-term indwelling seton for complex anal fistulas in Crohn's disease. Dis Colon Rectum 2005;48:459-63.  Back to cited text no. 11