Peri-anal Fistula Repair

An anal fistula is a narrow tunnel or tract running from the skin near the back passage and opening into the anal canal higher up. This discharges pus irregularly and may be uncomfortable. It often shows up after there has been an abscess near the anus. During the operation the fistula tract is identified and is opened along its length, and the exposed inside of the tract is then cleaned out. The wound is usually left open without suturing it. The wound becomes shallower as it heals, and ends up as a flat scar after a month or two. If it is too deep a drain can then be placed as a seton.

WHY IS THIS OPERATION NECESSARY?

The tunnel opening on the skin is connected to the inside of the anus and stool as well as organisms continues to travel along this tract, preventing healing. It becomes chronic and causes infection with intermittent pain or bleeding. It can cause repeated infections or abscesses and there is ongoing drainage or leakage from the fistula opening.

Peri-anal Fistula Repair
Peri-anal Fistula Repair

ARE THERE ALTERNATIVE TREATMENTS AVAILABLE?

Antibiotics may relieve the symptoms and draining the pus by a simple incision is possible, but it is likely then to return. Once a fistula has appeared, there is very little chance that it would heal without surgery. The alternative to cutting open the roof of the tract and laying it open is to excise the whole tunnel intact. This is called a fistulotomy and it sometimes involves closing the inside opening of the tunnel by suturing a flap of healthy mucosa over it. There are also treatments being studied where a tissue plug or glue is inserted in the tunnel to attempt sealing it off.

IS IT SAFE TO HAVE THIS OPERATION?

Before you agree to the operation, you should consider the risks that may be involved. Your surgery will be performed by a team of highly qualified and skilled professionals who will take all steps necessary to ensure a safe procedure and a successful result. However, there are risks involved with all surgery even if these risks may be small.

WHAT ARE THE GENERAL RISKS INVOLVED?

There are risks for developing complications which are general and which may occur with any surgical procedure. These complications include the risk of infection, bleeding, pain, wound breakdown, deep vein thrombosis, or complications affecting the heart, lungs or kidneys.

WHAT ARE THE SPECIFIC RISKS INVOLVED?

There is a chance of damage to the circular anal muscle. If the tunnel is found to run through the sphincter muscle, it would be unsafe to cut it open because the muscle would be damaged. In such a case the surgeon may choose to thread a thin plastic tube along its length and this is called a seton. This seton will then be left in the fistula tract to keep it open and allow drainage and promote healing. The seton would typically stay in position for 4 to 6 weeks after which it either falls out by itself or is removed with a simple procedure. Later complications may occur such as an anal stricture or narrowing of the anus opening. The chance of another fistula forming later on is about 10%.

WHAT ARE THE ANAESTHETIC RISKS INVOLVED?

You can discuss the type of anaesthetic you will have with your anaesthetist and also the possible complications that may occur.

IS IT SAFE TO HAVE THIS OPERATION?

Before you agree to the operation, you should consider the risks that may be involved. Your surgery will be performed by a team of highly qualified and skilled professionals who will take all steps necessary to ensure a safe procedure and a successful result. However, there are risks involved with all surgery even if these risks may be small.

WHAT ARE THE GENERAL RISKS INVOLVED?

There are risks for developing complications which are general and which may occur with any surgical procedure. These complications include the risk of infection, bleeding, pain, wound breakdown, deep vein thrombosis, or complications affecting the heart, lungs or kidneys.

WHAT ARE THE SPECIFIC RISKS INVOLVED?

There is a chance of damage to the circular anal muscle. If the tunnel is found to run through the sphincter muscle, it would be unsafe to cut it open because the muscle would be damaged. In such a case the surgeon may choose to thread a thin plastic tube along its length and this is called a seton. This seton will then be left in the fistula tract to keep it open and allow drainage and promote healing. The seton would typically stay in position for 4 to 6 weeks after which it either falls out by itself or is removed with a simple procedure. Later complications may occur such as an anal stricture or narrowing of the anus opening. The chance of another fistula forming later on is about 10%.

WHAT ARE THE ANAESTHETIC RISKS INVOLVED?

You can discuss the type of anaesthetic you will have with your anaesthetist and also the possible complications that may occur.

WHAT SHOULD I DO BEFORE THE OPERATION?

You should not eat or drink anything for at least six hours before your operation. However, you should take all your regular medication as usual on the day. Your surgeon may want you to stop certain medication such as disprin, warfarin, or other blood thinning medicines before the operation. Sometimes the surgeon will ask the nurses in the ward to give you an enema before you go to the operating theater

WHAT HAPPENS BEFORE THE OPERATION?

Please report to the hospital reception on time for your admission. Please bring along all the documents that may be required such as your medical aid card, ID and contact details. If you are not a member of a medical aid you will be required to pay a deposit or to sign an indemnity form. As far as possible we will try to advise you about hospital costs before your admission. It may be best to complete some of the documentation beforehand at the hospital pre-admission clinic to save time on the day of your admission.

When you arrive in the ward, you will be welcomed by the nurses or the receptionist and will have your details checked. Some basic tests will be done such as pulse, temperature, blood pressure and urine examination. You will be asked to hand in any medicines or drugs you may be taking, so that your drug treatment in hospital will be correct. Please tell the nurses of any allergies to drugs or dressings. The surgeon will have explained the operation and you will be asked to sign your consent for the operation. If you are not clear about any part of the operation, ask for more details from the surgeon or from the nurses.

In an adult the operation area may need to be shaved to remove excess hair. You may be issued with compression stockings that will help prevent blood clots in your legs. If you are having a general anaesthetic, the anaesthetist who will be giving your anaesthetic will interview and examine you and he may put up a drip or prescribe some medication to help you relax.

You will be taken on a trolley to the operating suite by the staff. You will be wearing a cotton gown; wedding rings will be fastened with tape and removable dentures will be left on the ward. There will be several checks on your details on the way to the operating theatre where your anaesthetic will begin.

HOW LONG DOES THE OPERATION TAKE?

Usually about 30 to 40 minutes

WHAT HAPPENS WHEN I WAKE UP?

After the operation is completed you will be transferred back to the ward. Although you will be conscious a minute or two after the operation ends, you are unlikely to remember anything until you are back in your bed on the ward. There will be a gauze dressing over the wound but this can be removed as soon as you go to the toilet for the first time.

WILL I HAVE PAIN?

Some pain may be present, but this should be controlled to a level of mild discomfort with the painkillers that are prescribed. The surgeon will usually inject local anaesthetic in the wound after the operation, but this will wear out after a few hours. Ask the nursing staff for medication if you have pain.

HOW SOON AFTER THE OPERATION CAN I EAT?

You can eat normally as soon as you wake up.

HOW SOON AFTER THE OPERATION CAN I GET OUT OF BED

You should be able to walk without too much discomfort as soon as you wake up and will be encouraged to mobilize as much as possible.

HOW LONG WILL I STAY IN THE HOSPITAL?

Usually you can go home on the same day. Some patients prefer to stay overnight, especially if the operation is scheduled in the afternoon.

WHAT HAPPENS WHEN I AM DISCHARGED FROM THE WARD?

Your surgeon will determine when you are ready to go home. You will be given some medication for pain and also medication to prevent constipation. Sometimes the surgeon will also prescribe antibiotics to take for five days after the operation. You will be given instructions on the dressings and how to care for the wound. You will also get an appointment for your follow-up in the surgeon’s rooms. You should ask for a sick certificate if you need this for your employer.

WHAT SHOULD I BE AWARE OF WHEN I GET HOME?

You should follow a normal diet and try to pass stool as normal. The first time you open your bowels it may be a bit painful but this rapidly improves. If you have not passed any stools after two days and you feel uncomfortable, contact the doctor. It is important not to become constipated. There will be an ooze of a small amount of blood-stained fluid so you could wear a pad to prevent staining your clothes. Sitz-baths are useful to clean the area two or three times a day but you could bath or shower as normal. Two tablespoons of salt in a shallow bath helps to aid the healing. The final healing can take up to two months.

HOW SOON CAN I START EXERCISE?

You can perform routine activities as soon as you get home. Mild exercise like walking or climbing stairs would be possible but you may find sitting down for long periods or activities like cycling can be painful for two weeks.

HOW SOON CAN I DRIVE A CAR?

You can drive as soon as you can drive safely without discomfort in the wound, usually after a week.

HOW LONG WILL I BE OFF WORK?

About two weeks