Fistula Management: Surgical Options and Quality of Life

Fistula issues

Hello, Dr.
Chang! My father is 86 years old, 160 cm tall, and weighs 45 kg.
He had an anal abscess that required three incisions for drainage.
After a week in the hospital, he returned home and had a follow-up appointment where three new fistula openings were identified.
However, due to the issue of fecal leakage being very close to the wound, the doctor recommended creating a stoma to prevent wound infection.
Three different doctors have declined to perform surgery.
I would like to ask:
1.
If surgery is not performed and a stoma is created, the fistulas may not easily become infected, but they also will not heal.
With ongoing care involving dressing changes and pus drainage, what could be the progression of this condition? Is it merely prolonging life? If there is no infection, will it just result in daily pain in the buttocks? Since creating a stoma does not improve quality of life, we are considering whether it is necessary.
2.
If surgery is not performed and a stoma is not created, and if there is no infection, aside from daily buttock pain, what other symptoms could arise that might pose a risk to life?
Thank you for your response, doctor!

ANITA C, 50~59 year old female. Ask Date: 2023/07/16

Dr. Zhang Shuhao reply Surgery

1.
If surgery to create a stoma is not performed and there is fecal leakage, frequent dressing changes and cleaning are necessary to prevent infection.
At this point, the patient's mobility should be considered.
If the patient is still able to care for themselves, they can manage bathing and dressing changes independently, and a stoma may not be necessary.
However, if the patient has limited mobility and is mostly bedridden, a stoma can reduce the frequency of dressing changes and cleaning, thereby improving quality of life and decreasing the caregiver's burden.

2.
If surgery is not performed and a stoma is not created, the wound may still be at risk for localized infection and inflammation.
This can lead to pain in the buttocks, and the infection may spread, resulting in new fistulas, abscesses, or necrotizing fasciitis, significantly increasing the risk of sepsis.
If conservative treatment is ineffective, it is advisable to consider stoma surgery early while the patient's physical condition still allows for it.

Reply Date: 2023/07/16

More Info

Fistula management, particularly in elderly patients like your father, requires careful consideration of both surgical options and the impact on quality of life. Given your father's age and health status, it's understandable that you are seeking clarity on the best course of action.

1. Understanding Fistula and Surgical Options: Fistulas, especially those arising from conditions like anal abscesses, can lead to significant discomfort and complications if not managed properly. The primary concern with untreated fistulas is the risk of recurrent infections, which can lead to systemic issues, including sepsis. If the fistula is not surgically addressed, it may persist, causing ongoing pain and discomfort. The recommendation for a colostomy (artificial opening in the abdominal wall) is often made to divert fecal matter away from the infected area, thereby reducing the risk of infection and allowing the fistula to heal. However, this comes with its own set of challenges, including the need for ongoing care and potential impacts on quality of life.

If surgery is not performed, and a colostomy is not done, the patient may experience chronic pain, drainage, and possibly recurrent infections. The quality of life could be significantly affected, as the patient may face daily discomfort and the psychological burden of living with a chronic condition. In some cases, if the fistula remains untreated, it could lead to more severe complications, such as abscess formation or even systemic infections, which can be life-threatening.

2. Quality of Life Considerations: If the decision is made to avoid surgery and not to create a colostomy, the patient may continue to experience pain and discomfort. While the absence of infection may seem favorable, the ongoing management of the fistula can be burdensome. Patients may require frequent dressing changes, and the presence of drainage can lead to skin irritation and further complications. The psychological impact of living with a chronic, painful condition should not be underestimated. Patients may experience anxiety, depression, and a reduced ability to engage in daily activities.

In terms of life-threatening conditions, if the fistula becomes infected, it could lead to sepsis, which is a medical emergency. Additionally, chronic inflammation and infection can lead to other complications, such as the development of new abscesses or even malignancy in rare cases.

In conclusion, the decision regarding whether to pursue surgical intervention or to manage the fistula conservatively should be made in consultation with a healthcare provider who understands your father's overall health status and quality of life goals. It may be beneficial to seek a second opinion from a colorectal surgeon who specializes in fistula management. They can provide a comprehensive evaluation and discuss the potential benefits and risks of surgical versus non-surgical options, including the impact on your father's quality of life. Ultimately, the goal should be to find a balance between managing the condition effectively and maintaining the best possible quality of life for your father.

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