Anal Fistulas in Infants: When to Consider Surgery

Anal fistula in infants

Dear Doctor, my son is currently almost 4 months old and has an anal fistula located at the 1 o'clock and 11 o'clock positions.
The pediatric surgeons we have consulted have advised against surgery for now, but the locations of the fistula are not common, and some doctors have mentioned that it could extend significantly.
Would it be better to consider surgery sooner? Previously, doctors have used a needle to puncture the abscess, which healed quickly, but it has been recurrently suppurating.

1.
Is it necessary to puncture the abscess, or will it rupture on its own?
2.
If we frequently drain the pus and ensure it is completely clean, will that prevent the fistula from extending further?
3.
Sometimes, excessive granulation tissue grows out; if we do not remove it, will it eventually regress on its own?
Due to the pandemic, I am concerned about the risk of infection in large hospitals and would like to hear your recommendations on whether surgery is urgently needed.
Thank you for your assistance.

Zhong Xiaojie, 20~29 year old female. Ask Date: 2021/01/31

Dr. Ke Fangxu reply Surgery

1.
If an abscess is not drained, the infection site may expand and eventually rupture on its own; therefore, early drainage is the correct approach.

2.
It is impossible to completely express the pus from an infection in the soft tissues around the anus; adults can utilize muscle contractions from walking to help drain the pus, but it is even more difficult for infants aged 3-4 months.

3.
Granulation tissue at the wound site is a normal part of the healing process and does not require special treatment.
If the infection can be controlled, emergency surgery should not be necessary.

Reply Date: 2021/01/31

More Info

Understanding anal fistulas in infants can be quite complex, especially when considering the timing and necessity of surgical intervention. In your case, your son is experiencing an anal fistula, which is a small tunnel that forms between the end of the bowel and the skin near the anus. This condition can lead to recurrent infections and discomfort, and it’s understandable that you are concerned about the best course of action.

When to Consider Surgery
1. Observation vs. Surgery: Many pediatric surgeons recommend a conservative approach initially, especially if the fistula is not causing significant symptoms or complications. The rationale behind this is that some fistulas may close on their own as the child grows. However, if the fistula is recurrently infected or causing significant discomfort, surgical intervention may be warranted. The fact that your son has had repeated episodes of pus formation suggests that surgery might be necessary to prevent further complications.

2. Location of the Fistula: The location of the fistula (at 1 o'clock and 11 o'clock positions) is indeed atypical, and while it may not be common, it does not inherently dictate the need for surgery. The concern about the fistula extending further is valid; if the fistula is not adequately addressed, it could lead to more extensive issues, including the development of more complex fistulas or abscesses.

Addressing Your Specific Questions
1. Is it necessary to puncture the abscess?: If an abscess forms, it often needs to be drained to relieve pressure and prevent further infection. While some abscesses may rupture on their own, this is not guaranteed, and waiting for this to happen can lead to more severe pain and complications. Therefore, if your son has a recurrent abscess, it is generally advisable to have it drained by a healthcare professional.

2. Does frequent drainage prevent the fistula from extending?: Regularly draining the abscess can help manage the immediate symptoms and may reduce the risk of further complications. However, it does not necessarily prevent the fistula from extending. The underlying issue of the fistula itself needs to be addressed, which often requires surgical intervention.

3. What about the granulation tissue?: Granulation tissue can form as part of the healing process. In some cases, this tissue may regress on its own, but it can also become problematic if it continues to grow or if it obstructs the normal function of the anal area. If the granulation tissue is excessive, it may need to be surgically removed.

Conclusion
Given your son’s age and the recurrent nature of his symptoms, it is crucial to have a thorough discussion with a pediatric surgeon who specializes in this area. They can provide a detailed evaluation and recommend whether surgery is necessary at this stage. While concerns about hospital environments during the pandemic are valid, the potential risks of leaving a fistula untreated may outweigh those concerns.
In summary, while some anal fistulas may resolve on their own, recurrent infections and the specific characteristics of your son's condition suggest that surgical intervention could be beneficial. It is essential to weigh the risks and benefits with a qualified healthcare provider to determine the best course of action for your son’s health and well-being.

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