Anal Fistula Surgery: Questions and Concerns Addressed

Anal fistula drainage line

Hello, Director Ke:
Last August, I underwent surgery for an anal abscess, and the wound healed well.
During my follow-up visit, the doctor said there was no fistula.
In May of this year, the same area became swollen and painful again.
The doctor performed a digital examination and also stated there was no fistula, but that surgery was necessary for improvement.
I was prescribed medication for a week to see if there would be any improvement; if not, surgery would be scheduled.
On June 7, I had a debridement surgery for the abscess at Taipei Veterans General Hospital.
The attending physician performed a digital examination and did not find a fistula.
On the day of the surgery, the resident physician checked again and also did not find a fistula.
After local anesthesia, I fell asleep and when I woke up, the surgery was completed.
The doctor informed me that there was indeed a fistula, but it was deep, and they used the seton technique.

I have a few questions:
1.
Why did both the outpatient doctor and the resident physician not detect the internal opening and fistula, yet it was identified during surgery?
2.
The seton technique requires four follow-up visits for tightening the suture.
After my first follow-up visit a week later, the suture fell out three days after.
During the second follow-up, the doctor said it was fine that it fell out and that I wouldn't experience pain anymore.
I am scheduled to return in a month to check the wound.
3.
After a month, the wound at the anal opening has not healed.
The wound on my buttocks has healed, but there is a small protrusion on the healing wound that is painful.
The doctor said to check again in October, and if it remains the same, they may scrape it off in the outpatient setting or perform another surgery to clean it out.

4.
Is this a sign that the surgery failed, leading to a recurrence just a month later with pain and protrusion? If it is a surgical failure, why can't another surgery be scheduled now? They mentioned that if surgery is performed now, the wound would be larger, and it is better to wait until the tissue has healed before proceeding with treatment.
5.
Should I seek a second opinion from another doctor?

BB, 40~49 year old female. Ask Date: 2016/07/22

Dr. Ke Fangxu reply Surgery

1.
Indeed, complex fistulas with deeper tracts can sometimes be difficult to diagnose, and there may be discrepancies in the diagnosis; fortunately, surgery can effectively address the underlying issue.
2.
This may be due to the surrounding tissue being less abundant in the area of the connecting strands.
3.
It could be due to incomplete healing of the external opening or the presence of granulation tissue.
4.
Determining whether the fistula has recurred requires a period of observation; undergoing surgery again in a short time may lead to incontinence due to damage to the sphincter muscle, so it is reasonable to reassess the surgical area after some of the wounds have healed.

Reply Date: 2016/07/22

More Info

Understanding anal fistula surgery can be complex, especially when complications arise or when the healing process does not go as expected. Based on your concerns, I will address each of your questions and provide additional context regarding anal fistula management and surgical procedures.

1. Discrepancy in Diagnosis: It is not uncommon for anal fistulas to be difficult to detect during physical examinations, especially if they are deep or if the internal opening is not easily palpable. The anatomy of the anal region can be quite complex, and sometimes the presence of a fistula may only become apparent during surgery. The surgical team may have used imaging techniques or their clinical judgment to identify the fistula during the procedure. It’s important to understand that the absence of a palpable fistula does not rule out its existence, particularly in cases where the fistula is deep or has a complex structure.

2. Suture Technique and Healing: The "stringing" or "seton" technique is often used in the management of anal fistulas, especially when they are complex. This method allows for gradual drainage and can help promote healing by keeping the fistula open. If the suture fell out prematurely, it may not have had enough time to facilitate proper drainage or healing. It’s essential to follow the surgeon’s instructions regarding follow-up visits and suture management, as this can significantly impact the healing process.

3. Healing and Pain: It is concerning that you are experiencing pain and a protrusion at the site of the healing wound. While some degree of discomfort can be expected after surgery, persistent pain or the formation of a lump may indicate incomplete healing or the presence of scar tissue. Your doctor’s recommendation to monitor the situation until the next appointment is likely based on the need for the tissue to heal adequately before further intervention. However, if the pain worsens or if you notice any signs of infection (such as increased redness, swelling, or discharge), you should seek medical attention sooner.

4. Surgical Outcomes and Recurrence: The recurrence of symptoms shortly after surgery can be frustrating and may lead to concerns about the success of the initial procedure. However, it is important to note that healing can take time, and some patients may experience complications that require additional treatment. Your surgeon's advice to wait for the tissue to heal before considering further surgery is standard practice, as operating on an inflamed or healing area can lead to more complications.
5. Seeking a Second Opinion: If you feel uncertain about your current treatment plan or if your symptoms persist, seeking a second opinion can be a wise decision. Different surgeons may have varying approaches to managing anal fistulas, and another perspective may provide you with additional options or reassurance regarding your treatment.

In conclusion, managing anal fistulas can be challenging, and the healing process may not always go as planned. It is crucial to maintain open communication with your healthcare provider, adhere to follow-up appointments, and report any concerning symptoms promptly. If you continue to have doubts or if your condition does not improve, do not hesitate to seek further evaluation from another specialist. Your health and comfort are paramount, and you deserve a treatment plan that addresses your concerns effectively.

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