Medicated Seton and Fistulotomy or Fistulectomy in the Management of Simple Anal Fistula: A Prospective Comparative Study

TL;DR

This study compares medicated seton and traditional surgery for simple anal fistulas, finding that medicated seton reduces pain, recovery time, and hospital stay while preserving sphincter function.

Contribution

The study provides new clinical evidence supporting medicated seton as a safer and more efficient alternative to traditional surgery for simple anal fistulas.

Findings

Medicated seton reduced operative time, postoperative pain, and hospital stay compared to fistulotomy/fistulectomy.

Patients with medicated seton returned to work and healed faster, with fewer complications and higher overall efficacy.

Recurrence rates were low and comparable between the two groups, with no significant difference at three months.

Abstract

Background

Fistula in ano is a persistent anorectal condition associated with pain, discharge, and recurrence. Traditional procedures such as fistulotomy and fistulectomy remain the standard of care for simple fistulae but may be associated with postoperative discomfort, delayed healing, and potential sphincter injury. Medicated seton offers a sphincter-preserving alternative that may enhance healing and reduce morbidity. The present study aims to compare the clinical effectiveness and safety of medicated seton versus fistulotomy or fistulectomy in the treatment of simple anal fistula.

Methods

This prospective comparative study enrolled 50 patients with simple anal fistula (St. James Grade I-II) between January 2024 and June 2025. In accordance with American Society of Colon and Rectal Surgeons (ASCRS) guidelines, only simple low intersphincteric and low trans-sphincteric fistulas were included. Patients were allocated into two groups of 25 each: medicated seton or fistulotomy/fistulectomy. Parameters assessed included operative time, postoperative pain (visual analog scale (VAS) at six hours), hospital stay, complications, work-off period, healing time, recurrence, patient satisfaction, and overall efficacy. Data were analyzed using the t-test and chi-square test, with p < 0.05 considered significant.

Results

Baseline demographics were comparable between groups. Operative time was significantly lower in the medicated seton group (18.6 ± 3.2 minutes) compared with the fistulotomy/fistulectomy group (28.4 ± 4.5 minutes; p < 0.001). Hospital stay (2.3 ± 0.8 vs 4.1 ± 1.2 days; p < 0.001) and postoperative pain scores (3.1 ± 1.2 vs 6.4 ± 1.6; p < 0.001) were also significantly reduced with medicated seton. Postoperative complications were low in both groups, with wound infection occurring in 2 (8%) vs 6 (24%), bleeding in 1 (4%) vs 3 (12%), and flatus incontinence in 0 vs 2 (8%) patients, respectively. Recovery outcomes favored medicated seton, including a shorter work-off period (8.2 ± 2.4 vs 15.6 ± 3.7 days; p < 0.001) and faster healing (6.2 ± 1.5 vs 8.9 ± 1.8 weeks; p < 0.001). Recurrence at three months was low in both groups, occurring in 1 (4%) vs 3 (12%) patients (p < 0.602). Overall efficacy was achieved in 23 (92%) patients in the medicated seton group compared with 19 (78%) in the fistulotomy/fistulectomy group.

Conclusion

Medicated seton was associated with reduced operative time, decreased postoperative pain, shorter hospitalization, quicker return to routine activities, and favorable healing outcomes. It offers a safe, effective, and sphincter-preserving option for managing simple anal fistula, with comparable recurrence rates to traditional surgery.

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