Anal fistula is a common disease in the community that impairs quality of life [7, 8]. The male‒female ratio of the patients in our study was found to be 3:1. Although this ratio is consistent with male population dominance in the disease, this ratio is generally accepted as 2:1 in the literature [9]. This can be explained by the small size of our study group or geographical differences.
In the seton group, we found that the use of setons was 80% in women and 50% in men. The high need for seton application in women in our study is due to the high incidence of complex and highly located fistulas. In the literature, it is seen that women have a higher percentage of low-level fistulas than men, at 70.2% over 50.3% [10].
In our study, we observed that the preoperative VAS and WHODAS 2.0 scores of the patients who were going to undergo seton and fistulotomy were similar. Pain was significantly higher in the fistulotomy group in the postoperative 1st week and in the seton group in the postoperative 1st month than in the seton group. In patients who underwent fistulotomy, pain was observed at the incision site in the first week postoperatively, especially during and after defecation. This pain subsides with recovery, so pain levels in the postoperative 1st month lag behind those in the seton group. The fact that the pain was less in the first postoperative week in the seton group may be attributed to better tolerance of the procedure than in the fistulotomy group, since there was no incision in the operation. In the first month postoperatively, while the pain decreased due to the healing of the incision site in the fistulotomy group, it was observed that the pain was higher in the seton group. This situation can be explained by the tension caused by the seton and the foreign body reaction. When we look at the literature, it is seen that the pain levels of the conventional drainage seton are higher than even the cutting seton [3, 11]. However, no study comparing it with fistulotomy has been found.
The results of the WHODAS 2.0 appear to be consistent with the results of the VAS. This is not surprising, as pain is an important factor in functioning. Apart from pain, other factors affecting functionality include difficulty in defecation, bleeding, discharge, and the presence of seton. The patients in the seton group could defecate more easily since there was no incision in the first postoperative week. Similarly, discharge and bleeding were observed less in the seton group in the first week than in the fistulotomy group. Since the fistulotomy incision healed in the first month postoperatively, bleeding and discharge were not observed. On the other hand, discharge continues in the seton group. In addition, the presence of setons may disturb patients during their daily life, thus reducing functionality.
When the WHODAS 2.0 subgroups were evaluated, the DAS 4 and 6 subscale scores were higher, and the loss of function in social life and human relations was higher in the seton group than in the fistulotomy group. The continuation of discharge and pain in the first month postoperatively in patients who underwent seton may cause them to keep themselves away from social activities such as religious activities and ceremonies. In a study evaluating the long-term follow-up results (3.65 years) of 22 patients, it was observed that the quality of life improved in all patients whose treatment was completed [12]. However, the follow-up period of our study was short, and a final fistula treatment had not yet been completed in the seton group.
Due to the higher risk of fecal incontinence after fistulotomy, compared to seton application, surgeons who do not have sufficient experience in the field of proctology are probably inclined to see seton application as a more innocent procedure, and they may apply it more liberally. However, it should not be forgotten that the concept of treatment includes not only the elimination of the existing disease but also protecting the long-term functionality of the patients. Therefore, it should be kept in mind that performing a seton for a more conservative approach instead of fistulotomy may result in more long-term pain and greater loss of function.