Fistula Treatment: Concerns About Threading and Healing Process

Regarding fistula ligation treatment?

Dear Dr.
Ke,
I recently underwent a fistula surgery using the thread method (also known as the cutting seton technique), which requires tying the thread once a week.
However, after the first tightening, during my second follow-up appointment (one week later), the doctor informed me that the thread had fallen out, and no medication was prescribed afterward.
During this period, my care routine involved sitting in a warm bath every four hours, and afterward, I used gauze to absorb the wound's drainage, changing it approximately every two hours.
I would like to ask for your clarification on the following points:
1.
I am concerned because I have seen many cases where the thread typically falls out after 2-3 tightenings.
In my case, the thread fell out after the first tightening.
Is this normal?

2.
The wound is exuding a green, viscous fluid.
Is this pus or tissue fluid?
3.
I have asked family members to visually inspect the wound, and they report that it appears to be healing well.
However, I have read many articles stating that the wound should heal from the inside out to allow for complete drainage of pus.
Therefore, it is necessary to massage both the internal and external openings.
If the external opening heals first, should I use a cotton swab to open it to facilitate pus drainage? If that is the case, could healing of the external opening lead to a recurrence due to incomplete drainage? How can I determine this?
The surgery date was March 26.
I apologize for the numerous questions and appreciate your guidance.
Thank you very much.

Niming, 30~39 year old female. Ask Date: 2016/04/14

Dr. Ke Fangxu reply Surgery

1.
The standard drainage technique typically requires 3-4 follow-up visits.
If the drainage line falls out after just one visit, it suggests that the original surgery might not have needed the drainage technique (the depth and length of the sinus tract can be addressed with traditional surgical incision).
2.
Wound exudate should be light yellow and clear; green, viscous discharge is unusual and should be evaluated by a physician.
3.
It is generally not recommended to intentionally massage the area; normal activity will facilitate drainage through muscle compression.
Frequent warm sitz baths can help maintain wound cleanliness and promote healing.
Whether there will be a recurrence may need to be observed over two to three months for confirmation.

Reply Date: 2016/04/14

More Info

Fistula treatment, especially when using the threading method (also known as seton placement), can be a complex process that requires careful monitoring and management. Here are answers to your concerns based on the information provided:
1. Threading and Line Detachment: It is not uncommon for the seton (the thread used in the procedure) to detach prematurely, especially if the tissue around the fistula is not yet strong enough to hold it in place. Typically, the seton is meant to stay in place for a period of time to allow for proper drainage and healing. However, if it detaches after the first tightening, it may indicate that the surrounding tissue is still fragile. It is essential to communicate this with your doctor, as they may need to assess the situation and possibly reinsert or replace the seton to ensure proper healing.

2. Discharge from the Wound: The green, thick discharge you are observing could be a sign of pus, which indicates an infection, or it could be a normal part of the healing process, known as serous fluid. If the discharge has a foul odor or is accompanied by increased pain, swelling, or fever, it is crucial to contact your healthcare provider, as these could be signs of an infection that requires treatment.

3. Healing Process: The healing of a fistula typically occurs from the inside out. If the external opening heals too quickly, it can trap pus or other fluids inside, leading to a recurrence of the fistula. It is essential to monitor the wound closely. If you notice that the outer opening is healing while there is still drainage, you should inform your doctor. They may recommend gentle massage of the area to facilitate drainage or may need to intervene to ensure that the internal portion of the fistula is healing correctly.

In general, the management of a fistula involves regular follow-ups with your healthcare provider to monitor the healing process. Here are some additional considerations for your care:
- Sitz Baths: Continuing with sitz baths as you are doing is beneficial. They help keep the area clean and can promote healing by increasing blood flow to the area.

- Wound Care: Changing the dressing regularly, as you are doing, is essential to prevent infection. Ensure that you are using sterile techniques when changing the dressing.

- Signs of Infection: Be vigilant for signs of infection, such as increased redness, swelling, warmth, or discharge that changes in color or odor. If you notice any of these signs, contact your healthcare provider immediately.

- Follow-Up Appointments: Regular follow-ups are crucial. Your doctor will assess the healing process and determine if any adjustments to your treatment plan are necessary.

In conclusion, while some variability in the healing process is normal, it is essential to keep an open line of communication with your healthcare provider regarding any concerns you may have. They can provide the best guidance tailored to your specific situation and ensure that you are on the right path to recovery.

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