Published: 2021-10-28

Polypropylene suture as a seton in recurrent fistula-in-ano in lower socioeconomic class-a good option

Kiran Patel


Background: Recurrent anal fistulas after previous fistula surgery are a unique problem that typically necessitates more anal surgical experience to address the cause of recurrence. The present study was planned with the objective to determine the outcomes of the polypropylene suture as a seton placement for the treatment of recurrent anal fistula.

Methods: Patients between the ages of 20-80 years with recurrent fistula-in-ano with single external opening and with history of previous surgery. Patients with preoperative incontinence, patients with difficult follow-up and who were not ready to participate in the study, patients with fistulas caused by inflammatory bowel disease, malignancy, tuberculosis, or trauma, patients with a horseshoe or multiple fistulas, patients with recurrent fistula-in-ano with multiple external opening, or recurrent fistula-in-ano with diseases like Crohn’s disease, tuberculosis, actinomycosis, malignancy, or high level fistula-in-ano without internal opening, and patients with synchronous anorectal problems such as haemorrhoids were excluded.

Results: Post-operative pain was observed in all patients while discharge, bleeding and inflammation were observed in 27, 10 and 8 patients, respectively on day 0. Majority of post-operative symptoms were resolves in almost all patients except, pain and discharge were observed in 2 and 1 patients, respectively on day 7. At 6 months follow-up, incontinence of flatus was found out in 2 patients while no patient had incontinence of faeces.

Conclusions: Polypropylene suture as a seton in recurrent fistula-in-ano, in previously operated patient is safe and most acceptable treatment. Ksharsutra is not easily available but polypropylene suture is easily available.


Polypropylene suture; Seton, Recurrent fistula-in-ano

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Jimenez M, Mandava N. Anorectal Fistula. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021 January 20. Available at: Accessed on 28 Jul, 2021

Kumar A, Kumar M, Jha AK, Kumar B, Kumari R. The Easiest Way to Insert Ksharsutra with the Help of an Infant Feeding Tube Instead of a Metallic Probe. Indian J Surg. 2017;79(4):371-3.

Panigrahi HK, Rani R, Padhi MM, Lavekar GS. Clinical Evaluation of Kshara sutra Therapy in the management of Bhagandara (Fistula-in-Ano)-A prospective study. Anc Sci Life. 2009;28(3):29-35.

Malik AI, Nelson RL. Surgical management of anal fistulae: A systematic review. Colorectal Dis. 2008;10:420-30.

Tozer P, Sala S, Cianci V, Kalmar K, Atkin GK, Rahbour G. Fistulotomy in the tertiary setting can achieve high rates of fistula cure with an acceptable risk of deterioration in continence. J Gastrointest Surg. 2013;17:1960-65.

Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg. 1976;63:1-12.

Dutta G, Bain J, Ray AK, Dey S, Das N, Das B. Comparing Ksharasutra (Ayurvedic Seton) and open fistulotomy in the management of fistula-in-ano. J Nat Sci Biol Med. 2015;6(2):406-10.

Seow-Choen F, Nicholls RJ. Anal fistula. Br J Surg. 1992; 79:197-205.

Pearl RK, Andrews JR, Orsay CP, Weisman RI, Prasad ML, Nelson RL et al. Role of the seton in the management of anorectal fistulas. Dis Colon Rectum. 1993;36(6):573-7.

McCourtney JS, Finlay IG. Setons in the surgical management of fistula in ano. Br J Surg. 1995;82(4):448-52.

Memon AA, Murtaza G, Azami R, Zafar H, Chawla T, Laghari AA. Treatment of complex fistula in ano with cable-tie seton: a prospective case series. ISRN Surg. 2011;2011:636952.

Bhat RP. Anal fistula with foot extension-treated by Ksharasutra (medicated seton) therapy-a rare case report. Int J Surg Case Rep. 2013;4(7):573-6.

Bubbers EJ, Cologne KG. Management of Complex Anal Fistulas. Clin Colon Rectal Surg. 2016;29:43- 9.

Emile SH. Recurrent anal fistulas: When, why, and how to manage? World J Clin Cases. 2020;8(9):1586-91.

Mennigen R, Laukötter M, Senninger N, Rijcken E. The OTSC(®) proctology clip system for the closure of refractory anal fistulas. Tech Coloproctol. 2015;19(4):241-6.

Dudukgian H, Abcarian H. Why do we have so much trouble treating anal fistula. World J Gastroenterol. 2011;17:3292-6.

Gurer A, Ozlem N, Gokakin AK, Ozdogan M, Kulacoglu H, Aydin R. A novel material in seton treatment of fistula-in-ano. Am J Surg. 2007;193:794-6.

Pankaj S, Manoranjan S. Efficacy of Ksharsutra (medicated seton), therapy in the management of fistula-in-ano. World J Colorectal Surg. 2010;2(2):1-10.

Akici M, Ersen O. The effect of suture selection in complex anal fistulas on the success of cutting seton placement and patient comfort. Pak J Med Sci. 2020;36(4):816-20.

Williams JG, MacLeod CA, Rothenberger DA, Goldberg SM. Seton treatment of high anal fistulae. Br J Surg. 1991;78:1159-61.

Parks AG, Stitz RW. The treatment of high fistulain-ano. Dis Colon Rectum. 1976;19:487-99.

Theerapol A, So BY, Ngoi SS. Routine use of setons for the treatment of anal fistulae. Singapore Med J. 2002;43:305-7.

El Mohamady MS. Cutting seton in management of complex perianal fistula–is it a safe procedure? Menoufia Med J. 2018;31(3):867.

Durgun V, Perek A, Kapan M, Kapan S, Perek S. Partial fistulotomy and modified cutting seton procedure in the treatment of high extrasphincteric perianal fistulae. Dig Surg. 2002;19:56-8.

Subhas G. Non-cutting setons for progressive migration of complex fistula tracts:a new spin on an old technique. J Colorectal Dis. 2011;26:793-8.

Al-Marzooq TJ, Hassan QA, Alnaser MK, Al-Edani MS. Treatment of Fistula-In-Ano with Tight (Cutting) Seton:Analysis of Outcomes and Efficacy Assessment. J Clin Diag Res. 2017;11(11):30017.

Subhas G, Bhullar JS, Al-Omari A, Unawane A, Mittal VK, Pearlman R. Setons in the treatment of anal fistula:review of variations in materials and techniques. Digest Surg. 2012;29(4):292-300.