Complications After Fistula Surgery: A Patient's Journey

Questions about anal fistula surgery?

Hello, Dr.
Hsu.
I would like to ask you some questions.
My family member underwent anal fistula excision surgery on July 19 under spinal anesthesia.
The surgeon sutured the wound in three layers, both internally and externally.
Before the surgery, I found some information suggesting that fistula surgery wounds can heal on their own without suturing, but the attending physician informed us that the wound was quite large, about 15 cm, and that suturing would promote faster healing.
However, the wound did not improve as expected and even began to show signs of infection, with pus and discharge leaking from the sutured area.
On the evening of August 3, during a follow-up visit, the attending physician stated that the sutured area was infected and needed to have the outer layer of sutures removed.
On August 4, a second surgery (suture removal) was performed under general anesthesia.
Currently, my family member is still in the hospital receiving care for the postoperative wound.
However, today, August 10, an attending physician visited the ward and explained that the wound continues to be infected and inflamed, and a third surgery is needed to remove the inner sutures.
The ward lighting was insufficient, so it was decided to perform the surgery under anesthesia tomorrow, August 11.
I am puzzled as to why an open healing approach was not chosen during the first surgery, and why the inner sutures were not removed during the second surgery, leading to multiple interventions.
The physician mentioned that each individual's healing process varies, but my family member is young and healthy.
I would like to ask if this situation is normal.
Thank you, Dr.
Hsu.

Shidanli, 20~29 year old female. Ask Date: 2016/08/10

Dr. Xu Kaixi reply Surgery

The surgical approach for anal fistulas is determined preoperatively based on various factors such as complexity, depth, and the presence of associated infections or abscesses.
Most simple fistulas, like the one your family member has, are treated with fistulotomy, while those with significant associated infections typically undergo incision and drainage (without suturing).
However, these principles are not absolute, and the final choice of surgical technique ultimately depends on the surgeon's professional judgment.
Among patients undergoing fistulotomy, a small number may experience poor wound healing and infection postoperatively, as seen in your family member.
The management principle, as you mentioned, involves reoperation to address the wound, which usually heals successfully over time, although it may require an extended recovery period.

Reply Date: 2016/08/10

More Info

Understanding complications after fistula surgery can be quite complex, especially when the recovery process does not go as expected. In your case, it seems that your family member underwent a fistula surgery on July 19, which involved a significant incision of approximately 15 cm and was initially closed with sutures. However, the subsequent complications, including infection and drainage from the surgical site, have raised concerns.

Firstly, it is important to note that the decision to either suture a wound or allow it to heal by secondary intention (open healing) often depends on the specifics of the case, including the size and location of the wound, the surgeon's assessment of the tissue quality, and the anticipated healing process. In some cases, especially with larger wounds, surgeons may opt for suturing to promote faster healing and reduce the risk of complications such as excessive scarring or prolonged healing times. However, if the wound is too large or if there is a significant risk of infection, an open healing approach may be more appropriate.

The fact that your family member developed an infection and required a second surgery to remove the outer sutures indicates that the initial closure may not have been the best choice for this particular case. Infections can occur for various reasons, including the presence of foreign material (like sutures), inadequate blood supply to the area, or the patient's overall health and immune response. It is also worth noting that even young and healthy individuals can experience complications post-surgery due to factors such as surgical technique, wound care, and individual healing responses.

Regarding the decision to perform a third surgery to remove the inner sutures, this could be a strategy to allow the wound to drain properly and promote healing. Infected wounds often require careful management, and sometimes, removing sutures can help facilitate drainage and reduce tension on the wound, which may be contributing to the infection.

It is understandable to feel frustrated and confused about the surgical decisions made by the medical team. Communication is key in these situations. If you have concerns about the surgical approach or the management of the infection, it is advisable to have a candid discussion with the primary surgeon or a specialist in wound care. They can provide insights into why certain decisions were made and what the expected outcomes are moving forward.

In summary, while it is not uncommon for complications to arise after fistula surgery, the specific circumstances of your family member's case—such as the choice of suturing versus open healing and the subsequent infections—highlight the variability in surgical outcomes. Each patient's healing process is unique, and ongoing monitoring and adjustments to treatment plans are often necessary to achieve the best possible recovery. It is essential to maintain open lines of communication with the healthcare team to ensure that all concerns are addressed and that the patient receives the appropriate care.

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