IN THE treatment of complex rectal Fistulae, neglected postoperative treatment, the failure to find he internal opening of he fistula, of the fistula, or the failure to excuse all the tracts of the fistula, will often subject your patient to one or more secondary operations.
It may be necessary to perform a two-stage operation to prevent the impairment of the anal sphincters. This is done by dissecting out the fistulous tract to the wall of the rectum and passing a section through the opening and into the bowel where it is loosely tied. The operation is completed on the fourth day under local anesthesia The internal opening is often in one of he crypts of the rectum.
If the proper technique and careful postoperative treatment of the wound are employed, no second operation is required even in complex fistula.
An extensive complex fistula may require the sacrifice of considerable tissue, and when the operation is completed your operative field may resemble a piece of raw beefsteak. However, to assure a cure you must excise all the tracts to their terminal ends. Always keep in mind that a fistula in ano is the result of an undrained abscess.
Forty-eight hours before the operation, have the patient take two ounces of castor oil (Jelks highball) and put the patient on a diet consisting of fruit juices, jello, gelatine, broths, coffee, tea and hard candy. Twelve hours before the operation, a high colonic irrigation of peroxide, four ounces, bicarbonate of soda two before the operation, give a low enema of one quart of warm water. This will insure an empty colon for a period of four of eight days. On the morning of the operation, the patient is given a hypodermic of morphine sulph. gr. 1/4. Ethylene gas is the anesthetic used.
The patient is put in the lithotomy position and the parts including, iodine and co alcohol., or merthiolate.
After the patient is draped, a small cannula attached to a luer syringe is inserted in the outer fistulous opening into high is injected a solution continuing equal parts of methylene blue and peroxide. This stains all the tracts of the fistula and makes it much easier to detect all of the opening, making more readily the dissection all of the opening, making more readily the dissection of the branches of the fistula to be excised.
It is the case o complex Fistulae, a large amount of indurated tissue is encountered which must be removed in order to attain a good result. After the excision is finished, make sure that all of the fine tracts. which if not seen may be detected by careful palpation with the fingers, are excised. In the case of tuberculous fistulae, the use of electrocautery may be preferred.
After the bleeding has been controlled, the wound is painted over with Merthiolate and packed with iodoform or plain gauze. On the third or fourth day, the wound is redressed and is lightly packed. After the bowels have moved, a sitz bath is taken and the wound is dressed with balsam peru, ichthyol 10 per cent, or merthiolate; gauze is laid lightly in the bottom of all tracts. After the first dressing, this is done daily for about ten days. Following this period, the wound is dressed every second day for two or three weeks, after which time the interval between dressing may be increased to twice a week.
The wound must be dressed so that it will heal up from the bottom. Great care must be exercised in the redressings to avoid bridging over and a prevent the formation of pockets. This can be avoided by daily dressing the wound and by the use of a dry cotton applicator for cleansing the deep pars of the wound. Irrigation with a solution of which-hazel; aids in keeping the tracts of the wound clean. Your postoperative care is even more important than the operation, and if carefully executed with assure success.
After the bowels have move, the patient is put on a full diet,. with the exception of meats,. alcohol and smoking. Get your patient as soon as possible out of the hospital and into the sunshine.
Finally, do not forget before operating to go upstairs with Dr. Jelks and have a good look.
Case A-Mr. Mr.H., aged fifty-six years. A very extensive complex fistula in ano with over external openings on the right buttock and one over the sacrococcygeal joint. There were two internal openings at the anus, one tract passing under and one over the external he had abscesses develop on the buttocks and was discharging pus into the sacrum and one connected with the bladder and posterior rectum.
On opening the fistulous tracts, September 18, we came upon a number of large pockets of pus which were excised. The large among of thirteen yards of packing was used in the first dressing. The patient was very sick and before he recovered a part of the scrotum and one testicle sloughed away. He also had great difficult in passing his urine which contained pus and albumin. He was discharged, entirely recovered, November 30-forty-two days duration.
Case B-Mr. W., aged twenty-nine years , had for the past three years, noticed a swelling on the left buttock. Hot applications were applied and as incision had made which relieved. After healing, however, they would open again. This condition existed for a number of years. There were two opening, one on either side of the buttocks, and an internal opening at the posterior anorectal line. There was a great deal of scar tissue in this case. A complete excision was made. The patient was operated upon October 14, and discharged December 6-fully recovered in fifty-four days.
Case C-Mr. S., aged fifty-one years, iron worker, weighing 200 -pounds, complained of severe pain for the past two weeks, with retention of urine. He said that during the past two years he had a number of openings which discharged pus. This time, however, they old not discharge. He was in great agony. The patient had an extensive cellulitis with a temperature of 105. Immediate incision was made and two quarts of pus were evacuated. A wet dressing was applied. A week later, January 30, the fistulous tracts,eight of them with two openings at the anorectal line above the internal sphincter were excited. The patient. The patient left the hospital February 24, and was entirely healed on May 1-ninety days.
Cases D-Mr. C., aged fifty-three years, had, else where, been operated upon seven times for a very extensive fistula in ano on nine years duration He had a fracture of the coccyx and sacrum, sustained from falling of the roof of a house,ten years ago. Both parents had died of carcinoma of the stomach. There we two opening on the buttocks and one in the rectum posteriorly. Both external tracts were excised and he was discharged May 2. The patient recovered in 103 days.
There has been no recurrence in the above, and a great many other cases.