Problems in treating anal fistulae
Perianal infective problems occur in two timelines - the acute problem presents as the anorectal abscess, a collection of pus and the chronic problem which presents as a fistula, a tube which periodically discharges pus. Both are devastating problems and cause lots of distress to the patients.
It is common to see patients suffering long with these problems. Are they really difficult to treat? If so, what are the difficulties? How can we solve them? I will attempt to answer your questions in this blog.
Like every "bottom" problem, the patients also present late, after enduring quite a bit of suffering. Anorectal infections present with pain - throbbing continuous pain. This pain is present all the time, unlike fissure pain that occurs when you pass stools. Sometimes, you may have fever.
The most important thing that you can do is to have an emergency surgical consultation.
The surgeon will examine you to determine the presence of infection and confirm the anatomy of the infection. In the Institute of digestive diseases, we do a preliminary examination in the OPD and on suspicion of the disease, plan an EUA (Examination under anasthesia). this enables us to completely evaluate the problem without causing pain and at the same time provide the necessary surgical care for the patient.
Every anorectal abscess (There are very rare exceptions) needs a surgical drainage. There is no role for isolated medical treatment in anorectal abscess. I do not mind stating this again and again, as I find quite a lot of my own patients trying out medical treatments in the hope that the problem would be solved. Not only will the problem remain, it is likely to worsen. The principle of pus drainage is very old (Ubi pus, ibi evacua - where pus, there evacuate) and you must understand that no antibiotic works under the acidic pH prevailing within the pus collection.
The drainage operation is a very simple one. It will keep you in the hospital for 2 days. Pus is sent for culture to see what kind of organisms caused the infection. If enteric organisms (E.coli, Klebsiella) are found, a second EUA is done 10 - 14 days after the evacuation of pus. This will enable a definitive treatment of the fistula at an early stage. We do not explore for the fistula track at the primary surgery. We find that the anatomy of the fistulous tract is difficult to locate in the inflamed tissues and serves no purpose. This protocol has served us well for several years and we continue to use it to benefit our patients.
If skin organisms are found in the pus, there may not be a need for a second EUA.
What if you have already developed a fistula? Once you develop a fistula, it is important to define the anatomy of the fistula. A fistula has 3 parts - the outer opening, the inner opening and the tract. The outer opening is the most obvious of the three. The inner opening and the track must be defined in order to provide the most appropriate treatment and give you a prognosis. It is in these issues failure usually occurs. If the surgeon fails to identify the internal opening or fails to identify a branching tract, the treatment is doomed to failure. But I would also state that it is not an easy affair to do this.
Systematic examination on established rules and careful use of radiology (fistulogram, MRI fistulography or an TRUS) will help the surgeon identify the tract, the branches and the relationship to the sphincter muscles responsible for the continence. we use dye staining techniques at the second EUA to delineate the track and stain the branching tracks to enable complete definition of the track. We also use sequential division of the track over a probe to lay open the track along the entire length.
We also routinely use a seton to loop the entire track to assess the muscle bulk needed to be divided.
At the institute, we routinely follow all the three methods to identify the track, assess the muscle bulk and provide the appropriate treatment. I must say that this has given good results to us so far, but I would also remember the failures I have seen over the past 10 years. For every patient, I make this rule - every aspect of the fistula must be defined and addressed at surgery. This is, I believe the most important aspect of the surgical care of the perianal fistula.
Now the options before your surgeon are laying open the track or to use a seton. If too much muscle needs to be cut, a seton is advised to slowly transect the muscle without any damage to the continence muscles. In all other patients, the fistula tract can be laid open.
Just laying open does not cure the fistula. This is another common error. The wound should be cared for, so that the wound heals from the bottom and the tract does not reform. Impatience in this time frame is not good.
What is your role? Patience. Fistula surgery may need one, two or rarely more than two surgeries. Patience is key to good results as you go through this process.
Good fistula surgery addresses all these facts. It must, for effective cure of these distressing problems.
It is common to see patients suffering long with these problems. Are they really difficult to treat? If so, what are the difficulties? How can we solve them? I will attempt to answer your questions in this blog.
Like every "bottom" problem, the patients also present late, after enduring quite a bit of suffering. Anorectal infections present with pain - throbbing continuous pain. This pain is present all the time, unlike fissure pain that occurs when you pass stools. Sometimes, you may have fever.
The most important thing that you can do is to have an emergency surgical consultation.
The surgeon will examine you to determine the presence of infection and confirm the anatomy of the infection. In the Institute of digestive diseases, we do a preliminary examination in the OPD and on suspicion of the disease, plan an EUA (Examination under anasthesia). this enables us to completely evaluate the problem without causing pain and at the same time provide the necessary surgical care for the patient.
Every anorectal abscess (There are very rare exceptions) needs a surgical drainage. There is no role for isolated medical treatment in anorectal abscess. I do not mind stating this again and again, as I find quite a lot of my own patients trying out medical treatments in the hope that the problem would be solved. Not only will the problem remain, it is likely to worsen. The principle of pus drainage is very old (Ubi pus, ibi evacua - where pus, there evacuate) and you must understand that no antibiotic works under the acidic pH prevailing within the pus collection.
The drainage operation is a very simple one. It will keep you in the hospital for 2 days. Pus is sent for culture to see what kind of organisms caused the infection. If enteric organisms (E.coli, Klebsiella) are found, a second EUA is done 10 - 14 days after the evacuation of pus. This will enable a definitive treatment of the fistula at an early stage. We do not explore for the fistula track at the primary surgery. We find that the anatomy of the fistulous tract is difficult to locate in the inflamed tissues and serves no purpose. This protocol has served us well for several years and we continue to use it to benefit our patients.
If skin organisms are found in the pus, there may not be a need for a second EUA.
What if you have already developed a fistula? Once you develop a fistula, it is important to define the anatomy of the fistula. A fistula has 3 parts - the outer opening, the inner opening and the tract. The outer opening is the most obvious of the three. The inner opening and the track must be defined in order to provide the most appropriate treatment and give you a prognosis. It is in these issues failure usually occurs. If the surgeon fails to identify the internal opening or fails to identify a branching tract, the treatment is doomed to failure. But I would also state that it is not an easy affair to do this.
Systematic examination on established rules and careful use of radiology (fistulogram, MRI fistulography or an TRUS) will help the surgeon identify the tract, the branches and the relationship to the sphincter muscles responsible for the continence. we use dye staining techniques at the second EUA to delineate the track and stain the branching tracks to enable complete definition of the track. We also use sequential division of the track over a probe to lay open the track along the entire length.
We also routinely use a seton to loop the entire track to assess the muscle bulk needed to be divided.
At the institute, we routinely follow all the three methods to identify the track, assess the muscle bulk and provide the appropriate treatment. I must say that this has given good results to us so far, but I would also remember the failures I have seen over the past 10 years. For every patient, I make this rule - every aspect of the fistula must be defined and addressed at surgery. This is, I believe the most important aspect of the surgical care of the perianal fistula.
Now the options before your surgeon are laying open the track or to use a seton. If too much muscle needs to be cut, a seton is advised to slowly transect the muscle without any damage to the continence muscles. In all other patients, the fistula tract can be laid open.
Just laying open does not cure the fistula. This is another common error. The wound should be cared for, so that the wound heals from the bottom and the tract does not reform. Impatience in this time frame is not good.
What is your role? Patience. Fistula surgery may need one, two or rarely more than two surgeries. Patience is key to good results as you go through this process.
Good fistula surgery addresses all these facts. It must, for effective cure of these distressing problems.
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