Postoperative Aftercare Following Anal Fistulectomy
After anal fistulectomy, avoid wound packing as it is costly, painful, and does not improve healing outcomes, while focusing on early oral intake within 4 hours, multimodal analgesia, and selective antibiotic use only for patients with sepsis, surrounding cellulitis, or immunosuppression. 1
Wound Management
- Do not routinely pack the wound after fistulectomy. A multi-center observational study of 141 patients demonstrated that packing is costly, painful, and adds no benefit to the healing process. 1
- The evidence on wound packing remains unclear based on a Cochrane review of 64 patients, with both included studies at high risk for bias, showing no clear benefit for time to healing, pain reduction, or fistula recurrence. 1
- If drainage is desired, consider placing a catheter or drain into the cavity with a small stab incision, leaving it until drainage stops, rather than traditional packing. 1
Pain Management
- Implement multimodal analgesia with integration of topical anesthetics and common pain killers for adequate pain control. 1
- For open procedures, thoracic epidural analgesia (TEA) is recommended for 48-72 hours given superior pain relief compared to systemic opioids. 1
- Monitor patients daily to optimize analgesia and facilitate early mobilization while limiting side effects such as hypotension, nausea, and vomiting. 1
Nutritional Support
- Resume oral ad-libitum diet within 4 hours after surgery. Early oral intake has been well-established as safe even with new colorectal anastomoses and is associated with reduced infectious complications. 1
- Offer oral nutritional supplements (ONS) in addition to normal food intake to maintain adequate protein and energy intake, as normal food alone cannot prevent postoperative weight loss. 1
Antibiotic Therapy
- Administer antibiotics selectively only in specific high-risk situations: presence of sepsis, surrounding soft tissue infection/cellulitis, or immune response disturbances (immunosuppression, neutropenia, diabetes). 1, 2
- A meta-analysis of 817 patients showed that empiric 5-10 day antibiotic course after drainage may reduce fistula formation from 24% to 16%, but this evidence is low quality and routine use is not recommended for uncomplicated cases. 1
- Among patients with surrounding cellulitis, induration, or systemic sepsis treated with drainage alone, there was a 2-fold increase in recurrent abscess compared to those receiving antibiotics. 1
- Sample drained pus in high-risk patients or those with risk factors for multidrug-resistant organisms. 1
Monitoring and Follow-up
- Clinical assessment of decreased drainage is usually sufficient for routine monitoring. 2
- Consider MRI or endoanal ultrasound combined with clinical assessment to evaluate fistula tract inflammation improvement if clinical response is unclear. 2
- Monitor for early wound dehiscence, which occurs in approximately 25% of cases with primary sphincteroplasty and may lead to keyhole deformity, particularly with posteriorly located fistulas. 3
Special Considerations for Complex Cases
- If sphincter reconstruction was performed (fistulectomy with primary sphincteroplasty), the median postoperative stay is approximately 7 days, with healing rates of 93-96% but a 12-4% risk of minor continence issues (mainly post-defecation soiling). 4, 5, 6
- Patients with recurrent fistula after previous surgery have a 5-fold increased risk of continence impairment and require closer monitoring. 6
- For Crohn's disease patients, maintain medical therapy with thiopurines, infliximab, or adalimumab before and after surgery to control inflammation. 2, 7
Critical Pitfalls to Avoid
- Never probe for residual fistula tracts during the postoperative period to avoid creating iatrogenic complications. 1
- Do not delay imaging in stable patients if there is concern for occult abscess or recurrence, but ensure imaging does not delay intervention in unstable patients. 2
- Avoid treating concomitant perianal skin tags in Crohn's patients, as this leads to chronic non-healing ulcers. 8, 7