title: Pulling Seton: Combination of mechanisms.
abstract: 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.
  
  
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Surgery, Colorectal Research Center, Shiraz, Iran.
authors.forename: Ahmad
authors.initials: A
authors.lastname: Izadpanah
authors.affiliation: Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Rezazadehkermani
authors.affiliation: Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: Seyed Mohammad
authors.initials: SM
authors.lastname: Hosseiniasl
authors.affiliation: Shiraz Blood Transfusion Organization, Shiraz, Iran.
authors.forename: Afrouz
authors.initials: A
authors.lastname: Farghadin
authors.affiliation: Department of Surgery, Colorectal Research Center, Shiraz, Iran.
authors.forename: Leila
authors.initials: L
authors.lastname: Ghahramani
authors.affiliation: Department of Surgery, Colorectal Research Center, Shiraz, Iran.
authors.forename: Alimohammad
authors.initials: A
authors.lastname: Bananzadeh
authors.affiliation: Department of Surgery, Colorectal Research Center, Shiraz, Iran.
authors.forename: Reza
authors.initials: R
authors.lastname: Roshanravan
authors.affiliation: Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: Ahad
authors.initials: A
authors.lastname: Izadpanah
keywords: Anal fistula; Seton; external anal sphincter; incontinence