Challenges After Deep Anal Abscess Drainage: Healing and Complications

After the drainage of a deep anal abscess, issues that may arise following wound healing include:

Hello Dr.
Ke,
First of all, thank you for taking the time to address my questions.
Last September, I underwent surgery at Linkou Chang Gung Memorial Hospital for a large deep perianal abscess, where three incisions were made radially from the anal margin to the right buttock, and one incision was made from the anal margin to the left buttock for drainage.
I was hospitalized for 18 days and followed the doctor's instructions for wound care at home, and all four drainage wounds healed sequentially.

In May of this year, I noticed a small bump about 0.5 cm in size under the skin near the anal margin of the healed incision on my left buttock.
Pressing on this bump with a cotton swab was painful, so I returned for a follow-up.
During the visit, the doctor re-opened the old wound with a scalpel to drain the pus.
I continued to return for follow-ups, but the small openings in the skin never truly healed.
In July, I underwent a suspected high anal fistula imaging study, which showed a tubular structure approximately 6 cm long (about 4 cm straight up and then bending left about 2 cm).
After confirming with the doctor twice, the imaging indicated that this tubular structure did not connect to the rectum, so I continued taking medication.
However, to this day, the small openings in the skin have not fully healed, and there is still a small amount of pus or blood-tinged fluid occasionally draining.
The bump near the anal margin, about 0.5 cm in size, has become very small, and pressing on it with a cotton swab is now almost painless.
I would like to ask you the following questions:
1.
Can fistula imaging be inaccurate? (I mean, is it possible for a tubular structure to connect to the rectum but not be visualized as such?) If so, what type of fistula might be incompletely imaged?
2.
Is there a way to determine the type of fistula before undergoing another surgery? Based on the description above, can you determine what type of fistula I might have? Or is it possible that it is not a fistula at all? If it is a high anal fistula, what surgical method would be the safest?
3.
Is it necessary to create a temporary colostomy when operating on a high anal fistula?
4.
The imaging shows a tubular structure about 6 cm long, but why can I never feel a hard tubular structure (I am of small stature and somewhat thin)? (Note: The small opening in the skin is about 2 cm from the anus.)
I appreciate your detailed explanation on these four points.
Thank you.

A Yi, 50~59 year old female. Ask Date: 2013/10/20

Dr. Ke Fangxu reply Surgery

1.
The so-called fistulography involves injecting a contrast agent into the fistula and then taking images.
If the pressure within the fistula is too high or if the rectal outlet is too narrow, it may indeed lead to a failure in imaging.

2.
Based on your description, it is unfortunate but quite likely that you have a high-level complex fistula.
However, it is not a problem if this cannot be confirmed preoperatively, as methylene blue solution can be injected into the fistula during the procedure for confirmation.
High-level complex fistulas are less likely to be treated with fistulotomy; instead, core-out or seton procedures are the primary surgical methods.
The former involves tubular excision of the fistula, while the latter uses a silk thread for long-term staged fistulotomy.
Please consult your attending physician for more details.
3.
If the high-level fistula is indeed severe, the possibility of a colostomy does exist, but it is generally avoided whenever possible.
4.
High-level complex fistulas are often very deep and may not be palpable.
Additionally, previous surgeries and the resulting scar tissue can also affect the assessment.

Reply Date: 2013/10/20

More Info

After undergoing drainage for a deep anal abscess, it is not uncommon to experience challenges related to healing and potential complications. Your situation, which involves a history of abscess drainage and subsequent issues with a possible fistula, raises several important considerations. Let’s address your questions one by one.

1. Accuracy of Fistulography: Fistulography is a diagnostic imaging technique used to visualize the anatomy of a fistula. While it is generally reliable, there are instances where it may not capture the complete extent of a fistula, particularly if it is high or complex. High anal fistulas, which may have a more intricate course, can sometimes be missed or inadequately visualized. If the fistula does not connect to the rectum, it may be classified as a non-communicating fistula or a simple abscess cavity. The type of fistula that might not be accurately depicted could include those with multiple branches or those that are located higher in the anal canal.

2. Identifying Fistula Type Before Surgery: Prior to any surgical intervention, it is crucial to have a thorough assessment. This may include additional imaging studies such as MRI or endoanal ultrasound, which can provide more detailed information about the fistula's anatomy and its relationship to the anal sphincter and rectum. Based on your description, if the imaging shows a tubular structure without communication with the rectum, it could suggest a high anal fistula or a remnant of the abscess cavity. However, definitive diagnosis often requires surgical exploration.

3. Need for Temporary Colostomy: The necessity for a temporary colostomy during the surgical treatment of a high anal fistula depends on the complexity of the fistula and the surgeon's assessment. In cases where the fistula is high and involves significant sphincter muscle, a temporary colostomy may be recommended to allow the surgical site to heal without the stress of stool passage. This decision is made on a case-by-case basis, considering factors such as the patient's overall health, the extent of the fistula, and the surgeon's preference.

4. Palpability of the Fistula: The inability to palpate a firm tubular structure despite the imaging findings can be attributed to several factors. Fistulas can be quite small in diameter, and in lean individuals, they may not be easily felt. Additionally, the fistula may be located deeper within the tissue, making it difficult to detect through external examination. The presence of a small opening on the skin surface, along with intermittent drainage, suggests that there may still be a connection to an underlying cavity or a low-grade infection.

In summary, your ongoing symptoms and the imaging findings suggest that you may have a complex fistula or residual abscess. It is essential to follow up with your healthcare provider for further evaluation and management. Surgical intervention may be necessary, and the approach will depend on the specific characteristics of the fistula. Open communication with your surgeon about your concerns and the potential need for additional imaging or surgical options is crucial for optimal management.

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