Seton Management Surgery: Potential Complications and Recovery Insights

Anal fistula is a condition that may have potential complications when treated with seton management surgery?

Dear Director Ke,
I have an anal fistula that began treatment with a seton placement surgery on February 25, 2022.
One-third of the fistula's total length is located outside the sphincter muscle, which the doctor treated with an incision, while the remaining two-thirds, which enters the sphincter area, was treated with a seton.
One week post-surgery, I had my first follow-up appointment for seton tightening, and subsequent follow-ups for tightening were every two weeks.
During each visit, the doctor noted that the new tissue was healing well.
After the surgery, the doctor did not instruct me to tighten the seton myself.
On May 15, during a follow-up visit, the seton fell out while the doctor was tightening it (approximately 11 weeks post-surgery).
The doctor mentioned that it would heal within a week and advised me to return if I experienced any discomfort.

As of October 10, the wound has shown no discharge, fecal matter, redness, or pain.
However, there is a slight indentation next to the anus, where the rubber band was placed during the seton procedure.
Sometimes, during bowel movements, this indentation (or "hole") gets soiled, requiring me to wipe it with wet tissue, although it remains clean when bowel movements are smooth.

I would like to ask you, Director Ke, about the cause of the indentation next to the anus.
Is it due to the prolonged pressure from the rubber band in that area? Or could it be a natural fold formed at the junction of the one-third incision and the two-thirds seton area due to different healing times? Or could there be other reasons, such as keloids or other factors? Will this indentation gradually fill in on its own? Generally, how long does this take? What is the maximum time it could take? If this indentation is not repaired, will there be any long-term consequences? If repair is needed, will it be handled by the original surgeon, or will I need to see a specialist? What is the best type of repair surgery, and what is it called? What risks or complications might arise from it? If I wish to repair the indentation, would it be better to wait until the skin in that area has filled in completely? Would this involve skin grafting? Is the risk significant? What are your thoughts on this?

Maike, 30~39 year old female. Ask Date: 2022/10/10

Dr. Ke Fangxu reply Surgery

The indentation and the rubber band should not be related, and there is no reason for it not to heal on its own.
It is more likely a remnant left from wound healing.
If there is no pain or infection, no special treatment is necessary.
If surgical repair is considered, I cannot answer many of your questions without a personal examination, as I do not know the specifics.
I recommend that you consult a surgeon for an examination and to inquire about related treatment options.

Reply Date: 2022/10/10

More Info

Understanding Seton Management Surgery: Potential Complications and Recovery Insights
Seton management is a surgical technique often employed for the treatment of anal fistulas, particularly those that are complex or involve the anal sphincter. This method involves placing a seton (a piece of material, often a rubber band or thread) through the fistula tract to promote drainage and allow for gradual healing. Your experience with this procedure, particularly the use of a seton for the portion of the fistula that traverses the sphincter, is quite common.

Causes of the Depression Near the Anus
The depression you describe near the anus could be attributed to several factors. One possibility is that the prolonged pressure from the seton may have caused localized tissue changes, leading to a slight indentation or depression. This is not uncommon, especially in areas where the tissue has been manipulated or subjected to pressure for an extended period.
Another potential cause could be related to the healing process itself. The area where the fistula was surgically treated may have different healing dynamics compared to the surrounding tissue, especially if one section was cut and another was managed with a seton. The differences in healing times and tissue remodeling can lead to irregularities in the surface contour, such as the depression you are observing.

Will the Depression Heal?
In many cases, such depressions can improve over time as the tissue continues to heal and remodel. However, the timeline for this can vary significantly from person to person. Generally, it may take several weeks to months for the tissue to fully heal and for any indentations to potentially fill in. If the area remains stable without signs of infection or significant discomfort, it is likely that it will continue to heal naturally.

Potential Long-term Effects
If the depression does not resolve on its own, it may not necessarily lead to significant complications, but it could cause cosmetic concerns or minor functional issues, such as difficulty in maintaining hygiene. If the depression becomes a source of discomfort or leads to recurrent infections, it may warrant further evaluation.

Repair Options
If you decide to pursue repair of the depression, it is advisable to consult with your original surgeon or a colorectal specialist. They will be best equipped to assess the area and determine the most appropriate course of action. The repair could involve techniques such as local flap advancement or even grafting, depending on the size and nature of the depression.

Risks and Considerations
Any surgical intervention carries risks, including infection, bleeding, and the potential for further complications. The specific risks associated with repairing a depression near the anus would depend on the chosen technique. For instance, flap procedures may have a risk of flap failure, while grafting could involve complications related to the donor site.

Timing for Repair
It is generally advisable to wait until the area has fully healed before considering any surgical repair. This allows the tissue to stabilize and reduces the risk of complications. Your surgeon will likely recommend waiting until the area has had adequate time to heal, which could be several months post-surgery.

Conclusion
In summary, the depression you are experiencing may be a normal part of the healing process following seton management for your anal fistula. While it is possible that it will improve over time, if you have concerns about its appearance or functionality, discussing these with your healthcare provider is essential. They can provide tailored advice based on your specific situation and guide you through potential repair options if necessary. Always prioritize open communication with your healthcare team to ensure the best outcomes for your recovery.

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