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Homeland Security plumbs new depths

The Lancet 2007; 369:370 Correspondence
Homeland security reaches the anus

“I wish to bring to your attention difficulties one of my patients
recently encountered when entering the USA. He is a 48-year-old man
with a fistula-in-ano managed with a long-term seton to control
perianal sepsis.

[Thanks Tim Chapman! Warning – Not for the faint of heart!]

A seton consists of a length of suture material knotted to form a
loop which lies in the fistula track. It passes through the fistula,
out of the external opening beside the anus, into the anus, and re-
enters the fistula through the internal opening. Various different
materials can be used; in this case the seton was made of a turquoise
braided synthetic suture. Many fistulas are treated with setons in
the short term, and, in those that are high or associated with
Crohn’s disease, this management can be long-term.

On arrival in New York in August, 2006, for a holiday, the patient
was interrogated by immigration officials, then examined and
searched. The presence of the seton gave rise to much concern, I
assume because of a suspicion that a drug package or terrorist weapon
was in some way attached to it. A rectal examination was done, during
which the examining official pulled very hard on the seton, causing
severe pain, but fortunately not damaging the anal sphincter muscles
encircled by it.

The patient was refused entry into the country unless the seton was
removed. Given the somewhat stark choice, he chose removal of the
seton, which was done by a doctor at the airport who claimed never to
have come across one before. The patient now requires an examination
under general anaesthetic to insert a replacement.

I thought I should highlight this rather bizarre manifestation of
“homeland security” because I suspect that it might become a more
frequent problem. I suggest that any patient with a seton who is
planning to travel to the USA or any other country where they are
likely to be searched in this manner should carry a letter from their
specialist explaining the nature of their condition and treatment.

I declare that I have no conflict of interest.”