Beyond traditional setons: multicenter outcomes of a hybrid approach for high transsphincteric fistulas

The surgical management of high transsphincteric fistulas (h-TSF) must balance high healing rates against the risk of fecal incontinence (FI). The hybrid seton technique (HST) aims to achieve this but lacks standardized protocols and robust outcome data. This study presents the multicenter results of an optimized HST for h-TSF. We performed a multicenter retrospective cohort analysis of prospectively collected data from patients undergoing HST for h-TSF. 72 patients at two tertiary centers were included. The procedure involved excision of the extrasphincteric tract, mechanical debridement, and placement of a latex glove-derived seton under mild tension, with marsupialization. Primary outcomes were one-year healing, recurrence, and FI rates, assessed using the Cleveland Clinic Incontinence Score (CCIS). The mean seton drop time was 20.9 ± 11.9 days with a median of 15.0 days (IQR, 14.0–28.0). At one-year follow-up, complete healing was achieved in 86.1% of patients (62/72; 95% CI, 76.0–93.1%). CCIS increased significantly at one-year compared with baseline. However, 84.7% of patients reported unimpaired continence (CCIS = 0 ; 61/72; 95% CI, 74.3–92.1%). Minor complications occurred in 16.7% of patients (12/72; 95% CI, 8.9–27.3%) and were managed conservatively. The HST appears to be a feasible option for the management of h-TSF, with acceptable success, continence, and complication rates. However, larger multicenter prospective randomized studies are required to confirm its safety and define long-term outcomes, particularly regarding FI.