Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.
World J Gastrointest Surg. Aug 27, 2026; 18(8): 118935
Published online Aug 27, 2026. doi: 10.4240/wjgs.118935
Cutting seton as salvage strategy for complex or recurrent anal fistula: Single-tertiary center 10-year experience with 207 patients
Mohammed A Widinly, Mahmood H Aljohani, Abdullah Alrebdi, Mohammed Basem Beyari, Saleh Husam Aldeligan, Aisha M Abdulrahman, Abdullah Alkassim, Hadi Almohsen, Rasha Eidah Althebaity, Eman Almotairi, Reem A Alharbi, Asim M Almughamsi, Nasser Alsanea
Mohammed A Widinly, Department of Surgery, Security Forces Hospital, Mecca 11481, Makkah Al-Mukarramah, Saudi Arabia
Mahmood H Aljohani, Department of Surgery, King Salman Armed Forces Hospital, Tabuk 71411, Tabūk, Saudi Arabia
Abdullah Alrebdi, Department of Surgical Oncology, Colorectal Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
Mohammed Basem Beyari, Saleh Husam Aldeligan, College of Medicine, King Saud University, Riyadh 11461, Saudi Arabia
Aisha M Abdulrahman, Department of Surgery, East Jeddah Hospital, Riyadh 11671, Saudi Arabia
Abdullah Alkassim, Department of Surgery, Imam Abdulrahman Alfaisal Hospital, Riyadh 14723, Saudi Arabia
Hadi Almohsen, Ministry of Health, Riyadh 11176, Saudi Arabia
Rasha Eidah Althebaity, Department of General Surgery, Prince Mohammed Bin Abdulaziz Hospital, Riyadh 14214, Saudi Arabia
Eman Almotairi, Department of Surgical Oncology, King Fahad Medical City, Riyadh 11525, Saudi Arabia
Reem A Alharbi, Nasser Alsanea, Surgery, Princess Nourah Bint Abdulrahman University, Riyadh 11564, Saudi Arabia
Asim M Almughamsi, Department of Surgery, Taibah University, Medina 42361, Saudi Arabia
Author contributions: Widinly MA and Almotairi E conceptualized the proposal, article, and study design; Aljohani MH, Alrebdi A, Abdulrahman AM, Alkassim A, Almohsen H, lthebaity RE, Almotairi E, Alharbi RA, and Almughamsi AM performed the data acquisition; Aljohani MH, Alrebdi A, Beyari MB, and Aldeligan SH conducted the data analysis and drafted the article; Alharbi RA and Alsanea N provided critical revision of the article for important intellectual content and approved the final version for publication.
AI contribution statement: The authors declare that no AI tools, including generative AI systems, large language models, or AI-assisted writing software, were used in the conception, design, data collection, data analysis, interpretation of results, writing, editing, or preparation of this manuscript. All content was created, reviewed, and approved solely by the authors.
Institutional review board statement: This study was conducted in accordance with the ethical principles contained in the Declaration of Helsinki, the International Council for harmonization harmonized tripartite good clinical practice, the policies and guidelines of the Research Advisory Council of the King Faisal Specialist Hospital and Research Center and the laws of Saudi Arabia. This retrospective study was approved by the Institutional Review Board of King Faisal Specialist Hospital and Research Centre.
Informed consent statement: Given the retrospective design of the study and use of anonymized data, the Institutional Review Board waived the requirement for obtaining informed consent from individual patients.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.
Corresponding author: Reem A Alharbi, Associate Professor, Surgery, Princess Nourah Bint Abdulrahman University, P.O. Box 4792, Riyadh 11564, Saudi Arabia.
reem.awad.alharbi@gmail.com
Received: January 19, 2026
Revised: April 28, 2026
Accepted: June 9, 2026
Published online: August 27, 2026
Processing time: 214 Days and 5.7 Hours
BACKGROUND
An ideal treatment for complex anal fistula that achieves a high success rate, low recurrence, and minimal risk of fecal incontinence has yet to be established. The cutting seton technique remains one surgical option for managing complex anal fistula. However, concerns persist regarding postoperative pain, recurrence, and sphincter-related complications.
AIM
To evaluate cure rate and clinical outcomes of cutting seton in the treatment of complex or recurrent anal fistula.
METHODS
A retrospective chart review was performed at an academic tertiary care center in Riyadh, Saudi Arabia. Patients diagnosed with complex or recurrent anal fistula between 2000 and 2016 at King Faisal Specialist Hospital and Research Center who were treated with cutting seton insertion were included (total n = 207). Primary outcomes were cure rate (complete healing), recurrence, and postoperative incontinence. Univariate and multivariate analyses were conducted to identify the risk factors for recurrence.
RESULTS
The cure rate was 89.4%. Recurrence occurred in 22 (10.6%) patients, 19 of whom were successfully cured with a second cutting seton and 3 treated with a third cutting seton. The median follow-up duration was 60 months. Preoperative and postoperative Cleveland Clinic Fecal Incontinence Scores were 1.62 (91.14-2.10) and 2.12 (1.58-2.66), respectively (P = 0.197). Only 25 patients (12.1%) reported new or worsened incontinence. Gas incontinence was the most common subtype reported (74%; 32/43), generally occurring rarely or occasionally per week. Univariate and multivariate analyses identified postoperative insertion of a Pezzar catheter as associated with recurrence (P = 0.021, odds ratio: 8.330, 95% confidence interval: 1.384-50.136). Pain was assessed in 180 patients, via the Visual Analog Scale, and demonstrated mild, moderate, and severe pain in 161 (89.4%), 15 (8.3%), and 4 (2.2%) patients, respectively.
CONCLUSION
The cutting seton is a reliable option for the treatment of complex and recurrent anal fistula, demonstrating a high success rate, a low incidence of predominantly mild gas incontinence, and manageable pain levels.
Core Tip: This study evaluated the outcomes of cutting seton use in the management of complex and recurrent anal fistula, including cure and recurrence rates, postoperative pain, and the risk of gas and fecal incontinence. The surgical technique was found to be a reliable treatment option, demonstrating a high cure rate, a low incidence of predominantly mild postoperative incontinence, and manageable pain levels.
