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Fistula Surgery : Purpose, Procedure, Benefits and Side Effects

Last Updated: Jun 24, 2023

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What is Fistula Surgery?

Fistulotomy or fistula surgery is done to completely remove a fistula so that it can heal into a flat scar. Surgery is necessary for the complete eradication of the fistula. Depending on where the fistula is and how severe the symptoms are, different surgical procedures are used. Pre-surgical processes are followed to determine the right type of surgery required by specific patients.

Types of Fistula Surgery:

Anal fistulas typically do not heal on their own, hence surgery is required to treat them. The type of surgery depends on various factors such as the position of the fistula and whether it is a single channel or branches out in several directions. There are numerous distinct processes to surgically treat anal fistula, some of which are;

Surgical Excision

Fistula does not disappear on their own and they require proper treatment to eradicate them. Also, there are various options available outside to treat fistula but surgery is regarded as important for the complete treatment of fistula. Surgeries for fistula usually require the insertion of general anesthesia to combat surgery pain. Some of the common surgical excision procedures for fistula treatment include-

  • Fistulotomy: It is one of the most common fistula surgery. The fistula is opened up along its whole length to encourage quick healing into a flat scar. It is quite effective for anal fistulas. It is often advised to treat the fistula which does not pass through much of the sphincter muscle. It possesses less continence.
  • Fistulectomy: it involves the complete removal of fistula surgery, hence regarded as a major surgery among all other procedures. It aids in reducing the chance of the secondary tract. In this procedure, the fistulous tract is laid open to promote fast healing.
  • Seton techniques: if the fistula is observed to pass through the anal sphincter muscle then the seton technique comes into the process. The tiny surgical thread that is put in to maintain the fistula open for several weeks is referred to as a "seton." It allows drainage and helps recovery. It also avoids the chance of cutting sphincter muscles.
  • Advancement flap procedure: when the fistula passes through the anal sphincter and fistulotomy poses a high risk of continence then the advancement flap procedure comes to the rescue. Nevertheless, compared to fistulotomy, it has a lower success rate. It comprises cutting and scrapping out of the fistula but neglects to cut off the anal sphincter muscles.
  • LIFT procedure: this procedure is applied in some cases where fistulotomy can posses too much risk. It has the ability to treat anal sphincter muscle fistulas. A cut is created in the skin just above the fistula, and then the fistula is sealed as a result of the procedure.
  • Endoscopic ablation: an endoscope is utilized in the procedure. An endoscope is made to pass through the endoscope and seals the fistula. It is considered safe and works well.

Summary- There are different kinds of surgical excisions available out there to treat fistula.

Glue or Plugs

A fibrin glue is injected by a surgeon after inserting general anesthesia. It helps to seal the fistula and promotes healing. It is currently the only non-surgical option available to treat fistulas. It is, however, less efficient than other surgical excisions.

Inserting a bioprosthetic plug is another procedure evident for treating the fistula. It is used to block the fistula's openings and is designed like a cone and made from animal tissue.

Summary- Glues, and plugs are non-surgical procedures applied to treat fistula but they are less effective than surgical ones.

Laser Therapy

Laser ablation is a relatively new fistula treatment method. The fistula channel is filled with a specific laser fiber. In laser procedure, a tiny laser beam is used in the radially emitting laser fiber treatment to close the fistula. To help the track heal and close up, a corona of energy is administered in 3mm to 5mm increments along the full length of the track.

Compared to standard surgery, laser fistula surgery often causes less pain and needs less recuperation time. There is less of a chance for incontinence. Laser treatment is best for initial treatments as it is 70% successful, and for subsequent 'improvement' treatments, it is 80% effective.

Both major operations and minimally invasive techniques can be used to treat anal fistula. High success rates, lengthy recoveries, and the possibility of negative side effects are all characteristics of fistulotomies and fistulectomies. While fistulectomies and fistulotomies have a high likelihood of success, they also entail lengthy recovery times and the possibility for negative side effects. Despite being simple processes, plugs and adhesive may not provide long-lasting benefits. Whereas, laser therapies might provide both fast recovery as well as positive success rates.

Summary- Laser ablation is one of the fistula treatment methods which requires less completion time.

Benefits of Fistula Surgery:

Surgery is the only effective treatment for a persistent anal fistula. Very few anal fistulas heal on their own. The quality of a person's life can be substantially impacted by a fistula. Fistula surgery is successful for the majority of patients, and recurrence rates are minimal. For instance, a fistulotomy has a success rate of 92–97% over the long term.

Here are some of the many benefits of fistula surgery;

  • No anal abscesses post surgery
  • Pain and swelling around the anus also cured
  • Bloody or foul-smelling drainage (pus) and the pain may decrease after the fistula drains
  • No more pain with bowel movements
  • No more bleeding

Summary- Benefits of fistula surgery include- treatment of pain and swelling, painless bowel movements, reduction of anal abscesses, etc.

Why is Fistula Surgery done?

Fistulas can develop as a result of surgery, bodily injury, or severe inflammation brought on by an infection or inflammatory bowel diseases like Crohn's disease and ulcerative colitis. A fistula surgery is needed to cure the infection and drain the abscess that resulted from these conditions. The aim of surgery is to seal the fistula while avoiding damage to the sphincter muscles, a ring of muscles that open and close the anus and is responsible for bowel control.

Fistulas must be treated since they won't heal on their own; and when they really don’t, there is a possibility that cancer will spread to the fistula tract. The majority of fistulas require surgical intervention.

Summary- Fistula surgery is done to relieve the fistula symptoms and their adverse effects.
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What are the risks of Fistula Surgery?

Just like any other form of surgery, Fistula Surgery entails some risks. The primary risks are:

  • Infection: If severe, this may need to be treated in a hospital with a course of antibiotics.
  • Recurrence of the fistula: Despite surgery, the fistula might occasionally come back.
  • Bowel incontinence: It is a potential complication associated with the majority of anal fistula treatments, while severe incontinence is uncommon and will be avoided at all costs.

The location of your fistula and the particular procedure you have will affect the level of risk. Ask your surgeon about any possible dangers associated with the recommended operation procedure.

Summary- Some risk factors often associated with fistula surgery are- bowel incontinence, recurrence of the fistula, and certain infections.

How do I prepare for Fistula Surgery?

As general anesthesia is used during anal fistula surgery, you will be sleeping throughout the operation. Hence, there are some preparations like refraining from eating and drinking hours before going to the operation theater. Some of the preparations for anal fistula surgery are;

  • Need to fast for six hours. However, up until two hours before the procedure, some anesthesiologists permit brief sips of water
  • Nurses may take your heart rate, blood pressure, and urine samples while you're in the hospital
  • Nurse may prepare you with a bowel washout (an enema)
  • In order to prevent blood clots from forming in the veins in your legs, you could also be required to wear compression stockings or an anti-clotting medication, which may be administered intravenously in place of stockings
  • A consent document will be provided to you by your surgeon. This attests to the fact that you are aware of the procedure's risks, advantages, and potential substitutes and have given your consent for it to proceed.

Summary- Before undergoing fistula surgery, we need to follow some rules to be prepared for the surgery.

How is Fistula Surgery done?

Typically, the procedure lasts 30 minutes. Depending on the type of fistula you have, a specific operation will be required. Your surgeon will evaluate the fistula and choose the most effective course of action. Your healthcare professional will do a digital rectal exam using a gloved finger to estimate the size and location of the fistula in order to decide whether fistulotomy is necessary. The digital exam, if carried out by a gastroenterologist, can be sufficient to determine the initial diagnosis.

Surgeons often let fistula 'lay open' if it is only superficial so that it can begin to mend inside. At times, it's important to leave a thread of material, such as suture material, in the fistula tract. It might be necessary to leave a seton in place for a while. The fistula is often covered with a bandage until it has entirely healed. To close the fistula, a unique protein-based glue or plug may occasionally be employed.

Summary- Fistula surgery is carried on by following some distinct procedures as stated above.

Before the Surgery

Most patients who have fistula surgery won't need to spend the night in the hospital and can return home the same day as long as everything goes well, without any issues. If the fistula is tiny and shallow, the operation could just require local anesthesia. If not, a surgeon will use a general anesthetic to put the patient to sleep.

You will have to sign the required consent documents before getting started for your operation. Your intravenous (IV) line will be put into a vein in your arm after your vital signs have been assessed in order to administer medication and fluids.

You will also meet with the anesthesiologist to discuss any drug allergies you may have and whether you've ever experienced anesthesia-related side effects. The type of anesthesia being used and the rationale for it should also be disclosed to you by the anesthesiologist.

During the Surgery

You'll probably receive either a general anesthetic to put you to sleep entirely or a type of sedation called monitored anesthesia care (MAC) to induce light sleep after you've been prepared for surgery. Your IV will be used to administer this.

However, if the fistula is small and close to the skin's surface, all that may be required to assist numb the area is an injection of a local anesthetic. An anesthesiologist may not be required in such circumstances.

Through the IV line, preoperative antibiotics will be administered to aid with healing and to avoid infection.

You might be positioned in one of three ways, depending on where and how the fistula is:

  • Supine position: Lying face down on a table
  • Position for Kraske: Jackknife-style facing down on an inverted V-shaped table
  • Laying on your back: With your legs and calves in raised stirrups at a 90-degree angle is the lithotomy position.

The healthcare professional will perform a fistulotomy to open the irregular gap between the two structures. While the anus is being softly opened by an anal retractor, the fistula is being surgically cut. The anal sphincters shall be protected as much as possible to prevent or minimize harm.

The base of the wound is curetted once it has opened (scraped). The wound is then left exposed to allow natural healing. If necessary, marsupialization (the stitching of the cut borders of the incision) can be done to encourage drainage, lessen bleeding, and improve pain management.

To assist keep the wound clean, the wound is then either packed with gauze or coated with it, then wrapped. Depending on the size and location of the fistula, a fistulotomy may take 30 minutes to an hour to complete.

After the Surgery

You are transferred to a recovery room following surgery, where you are supervised until you are awake. If you feel queasy, food and drink may be provided in addition to anti-nausea medicine. Even if a local anesthetic was given during the procedure, it is usual to feel pain and discomfort in the lower abdomen right away following a fistulotomy.

The nurse will send you home with painkillers, antibiotics, sanitary napkins or diapers, and wound care instructions as soon as you are stable enough to walk and change into your clothes. You will need a friend or family member to pick you up and, ideally, stay with you overnight to watch out for any difficulties.

Before returning to regular activities, such as going to work, you will likely need to take at least a week off. Some people require a two-week period of rest. You'll probably need to take painkillers for a few days after the procedure. Applying gauze or soaking the wound in a warm water basin may also be necessary.

Here are different surgical procedures that are done differently based on the patient's condition and requirement;

  • Fistulotomy: This procedure involves severing the fistula along its whole length to open it and promote quick healing of the flat scar. It is evident in the case of treating many anal fistulas. It also accompanies low complications. The surgeon creates a small incision of the anal sphincter muscle to treat the fistula.
  • Fistulectomy: it comprises complete excision of the fistulous tract, eradicating the risk of missing secondary tracts. It provides complete tissue for histopathological examination. This procedure ultimately results in fast healing.
  • Seton Surgery: This surgery typically takes an hour or so to complete for an anal fistula, though this can change depending on how complicated the fistula is. The process will be carried out while the patient is under anesthesia. A light, padded dressing will be applied to the fistula once the surgeon has inserted the seton. A patient can need additional operations to correct or replace the seton because surgical teams frequently execute seton insertion surgery in phases. The fistula may continue to drain for a few weeks after surgery.
  • Advancement flaps: If the fistula runs through sphincter muscles and fistulotomy is too risky, advancement flaps may be required. A flap of tissue obtained from the interior of the rectum will be used to cover the hole where the fistula entered after it has been cut or scraped out in this instance.

Although there is a tiny chance of failure, this lowers the possibility of complications.

  • LIFT Method: Prior to separating from the sphincter muscles, the LIFT method entails making a tiny cut above the fistula. The fistula will subsequently be sliced open so that it rests flat after being sealed at both ends. Since this process is still very new, additional information must be gathered. It is, nevertheless, promising.
  • Endoscopic ablation: A tiny tube equipped with a camera is used in endoscopic ablation to view the fistula. To close the fistula, an electrode will next be inserted through the endoscope. This has been demonstrated to be efficient with a low risk of problems.
  • Laser Surgery: laser technique is a technique to close a fistula but utilizing a laser fiber. It is often inserted into the fistula to the rectum's entrance. Using a laser beam, the fistula is sealed inside of the body.

The only non-surgical treatment is fibrin glue, which is injected into the fistula while the patient is under general anesthesia. The fistula will be sealed as a result, promoting healing. Compared to fistulotomy, it is less effective and might only be temporary. However, it can avert surgery.

The sort of procedure a person underwent and how intricate it was can determine how long it takes them to recover after fistula treatment. The surgical team can offer individualized guidance on how to recover.

How much does Fistula Surgery cost?

In India, the cost of a fistula surgery can range from Rs. 45,000 to Rs. 60,000. Here is an estimated cost of anal fistula surgery across various cities in India;

The type of hospital and other varied elements could also influence this pricing variance. The price of fistula surgery depends on some of the following variables, such as;

  • The kind of hospital and its location
  • Consultation fee of the doctor
  • Charges for transportation to and from the hospital
  • The price of laboratory or diagnostic tests
  • Type and grade of treated piles (grade I, grade II, grade III, grade IV)
  • Technology used in surgery
  • Any other pre-existing medical condition
  • The kind of operation done
  • Pre and post-operative appointments’ charges
  • The cost of hospitalization
  • Daycare charges
  • Medication charges
  • Insurance cover

Notably each of these factors may have an impact on the price of an Indian fistula surgery. So, consider each of these factors when estimating the cost of a fistula operation. You can also look into your insurance coverage for the costs of your fistula surgery.

Summary- Fistula treatment costs usually lie between 45,000-60,000.

What to do after Fistula Surgery?

Your doctor could give you a handful of instruction for fast and smooth recovery and to subside the pain and other problems that could arise post fistula surgery;

  • Sitz bath, which involves bathing the affected area in warm water. In a sitz bath, you need to sit in warm salty water (8 to 10 cm) for 15 to 20 minutes per day
  • Laxatives or stool softeners for a week
  • Rest until the anesthetic's effects wear off in order for the abscess and fistula to heal correctly and hopefully prevent a recurrence
  • Your doctor may prescribe painkillers or inject a local anesthetic to ease your discomfort after your general anesthetic wears off
  • Daily dressing of the wound formed after surgery until it heals.
  • A course of antibiotics. It's crucial to finish the course of antibiotics if you've been prescribed them.

Summary- We should follow some post-surgical tips to avoid complications.

What to eat after Fistula Surgery?

You may consume your typical diet. Try bland, low-fat items such as plain rice, grilled chicken, bread, and yogurt if your stomach is disturbed. Drink a lot of water (unless your doctor tells you not to). Every day, include high-fiber items in your diet, such as fruits, vegetables, legumes, and whole grains. Here are some of the food items that you can easily consume after anal fistula surgery;

  • Cereals: Brown rice, oatmeal, broken wheat, ragi, quinoa
  • Pulses: Chickpeas, kidney beans, moong dal, masoor dal, soybeans
  • Vegetables: All gourds-bitter gourd, snake gourd, ridge gourd, bottle gourd, ivy gourd, ladies finger, tinda, green leafy vegetables
  • Fruits: Custard apple, pears, grape and watermelon, oranges and apple
  • Milk and milk products: Skim milk, paneer, cottage cheese, yogurt
  • Meat, Fish and Egg: Tuna, salmon, herring, mackerel.

Summary- We should incorporate nutritious foods to combat fistula.

Is Fistula Surgery safe?

Just like any other surgery anal fistula also has its fare share of complications. Any procedure could have unanticipated side effects from the anesthetic, excessive bleeding, or the development of a blood clot, typically in a vein in the leg (Deep Vein Thrombosis or DVT). Although they are very rare.

Here are some specific complications that can arise from anal fistula surgery:

  • Infection: This may lead to an anal abscess and require further treatment
  • Injury to the sphincter muscles: This can cause fecal
  • incontinence and disrupt bowel control

Summary- Although, fistula surgery consists of certain complications it is considered safe.

Is Fistula Surgery painful?

As patients are administered general anesthetic, putting them to sleep, or regional anesthesia, which keeps the patient awake but numbs the area which is to be operated on, it is highly unlikely for them to feel any pain or discomfort during the anal fistula surgery. Although, as the anesthetic wears off, you might experience some discomfort, but your medical staff will provide you with painkillers.

Moreover, following the surgery, you probably won't feel completely comfortable for around a week and may experience some pain and bleeding from the wound. For such tough times your surgeon may prescribe you some over-the-counter painkillers like paracetamol or ibuprofen.

Summary - Fistula surgery involves the administration of anesthesia to combat pain.

How long does it take to recover from Fistula Surgery?

It should take around six weeks for your wound to completely heal. You might need to return to the hospital every day so that they can change the dressings to help keep your wound clean and heal, depending on the extent of the wound. How long you will require dressings will also be discussed by your surgeon. You might find it helpful to wear a gauze pad in your underwear for the first week or two to protect your clothing from any wound leakage.

Summary - Usually 2 months are required for recovery from fistula surgery.

What are the side effects of Fistula Surgery?

A person may have the following side effects after anal fistula treatment:

  • Cramping
  • Nausea
  • Constipation
  • Diarrhean
  • Pain at the wound's location

Once the body starts to heal, these adverse effects ought to disappear after a few days.

Summary- There are some adverse effects often accompanied by fistula surgery.

Fistula Surgery Aftercare

Following surgery, it's crucial that patients relax for a few days. Along with some rest, your doctor may also recommend some aftercare to help ease the pain and ensure a normal recovery. Here are some aftercare tips for patients with anal fistula surgery;

  • Rest until the anesthetic's side effects wear off
  • Stand up and move around a little with your nurse's help when you're ready. This will lessen the likelihood of difficulties
  • Take painkillers provided to you by the medical staff to soothe the pain and discomfort after your anesthesia wears off following the operation
  • If a topical ointment was prescribed, apply it to the anal surface and a small amount inside the anal canal 2-3 times per day
  • Don't drive, consume alcohol, use machinery, or make any significant decisions in the interim
  • Follow a diet that is high in fiber, is not extremely oily or spicy, and has lots of clear fluids, for regular soft stools
  • Engage in regular, gentle exercise because it will improve both your physical and emotional health
  • Your healing will be assisted by consistent showering, sleeping, and relaxing

Visit clinic for follow-up care

After surgery, if you experience any urination issues, you could initially require a catheter (a tube that drains urine from your bladder).

Follow the instructions of your doctor on how to take care of your wounds, how to spot infection symptoms, and how to take pain medication after leaving the hospital

Also, schedule a follow-up appointment with your doctor as directed by your treating medical professional. The initial follow-up appointment is typically scheduled for 3 weeks after surgery, although if a seton was implanted, the doctor might want to see you sooner.

Summary- Aftercare tips are very effective in soothing the recovery phase.

Conclusion

Living with a fistula is rarely a lifelong condition given the variety of surgical treatments available in today's world. Fistula diagnosis, treatment, and recovery can take a long time and be frustrating. However, with so many treatment options anyone can get their fistula removed irrespective of their age and severity of the condition.

Also, diet, hygiene and exercises play a crucial role after anal fistula surgery, hence you should follow the guidance of your healthcare provider to heal your wounds soon.

References

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Written ByDr. C.S. Ramachandran DNB (General Surgery),FICS,MBBS,MS - General Surgery,FCCP (USA)General Surgery
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