I often hear post-operative patients say that they have to go through “two major tortures” every day: one is “defecation” and the other is “medication change”. I’d like to talk about the “bitter pill”, the early post-operative anal fistula must adhere to the daily change of medication, the recovery of this disease, 5 points by surgery, 5 points by the change of medication. The main reason for this is the fact that the fistulas are not self-healing, and the clinical cure is mainly through surgery, and the surgical wounds are mostly open, so it is especially important to change the medicine.
What is an anal fistula?
It is commonly believed that after a perianal abscess due to purulent infection of the anal glands breaks down, the fibrous tissue of the abscess proliferates and the abscess cavity shrinks to form a fistula, and a fistula can also form as a secondary infection from trauma to the rectum and anal canal.
The average age of patients is 38.3 years old, with a male to female ratio of 1.8:1.0, and most patients younger than 15 years old are male. The incidence of anal fistula is predominantly in young people and is significantly higher in men than in women, in line with the clinical situation, so it has been hypothesized that androgens are a major cause of anal fistula formation.
Treatment of anal fistula
The treatment of anal fistula can be divided into non-surgical and surgical treatment.
Non-surgical treatment is mainly to control the infection and reduce the symptoms through medication, but cannot cure it completely, while surgery aims to remove the infected anal glands and remove the infected foreign body from the fistula, which is the key to treatment. Most of the anal glands are concentrated in the posterior part of the anal canal, but they can also straddle the dentition line and can also be located above the dentition line, so when removing the internal orifice, it can be properly extended upward to completely remove the infected anal glands.
Common surgical approaches include non-sphincter-preserving approaches and sphincter-preserving approaches. The non-sphincter-preserving methods mainly include sphincter hanging, incisional and incisional sphincter hanging. The sphincter-preserving methods mainly include endogastric suture drug decannulation method, endogastric closed tube drainage method and open plus incision or hanging wire method.
Due to the different conditions and symptoms, there are various methods of anal fistula surgery, which can also be used in conjunction with each other during the operation.
Method of changing medication after anal fistula surgery
After anal fistula surgery, the correct method of changing medication can promote the growth of the wound, accelerate healing, reduce patient pain, shorten the hospital stay, and lower the patient’s hospital costs. If the medication is not changed properly, even if the surgery is successful, the wound healing will be slow, which will not only prolong the hospital stay and increase the pain, but may even lead to the formation of anal fistula again and require another surgery, adding unnecessary pain and cost to the patient. It is important to note that post-operative medication changes are just as important as surgery, so all anal surgeons and patients should pay more attention to them.
The postoperative medication change for anal fistula should follow the degree of wound healing
1. debridement period (inflammation period)
For 3 to 5 days after surgery, the wound is mainly inflammatory exudate, i.e. there are more wound secretions and pus rot is not exhausted. This period of drug exchange is to get rid of foreign bodies and necrotic tissues in the trauma surface and trauma cavity, to make the wound drainage smooth, to reduce the stimulation of bacterial reproduction and secretion, and to prevent concurrent infection. Traditionally, iodine solution, hydrogen peroxide, benzalkonium bromide solution, and body saline are mostly used for flushing. Physiological saline is the safest wound cleansing solution because it does not contain any antiseptic additives, is non-toxic, and conforms to human physiology. For large pus cavity, more pus, especially necrotic tissue, early selection of 3% hydrogen peroxide rinse, the use of hydrogen peroxide need to be cleaned with physiological saline rinse, when the purulent fluid reduced or odor reduction, that should stop the application of hydrogen peroxide, only physiological saline rinse can be. If the infection, the traditional choice of Huanglian water, furacilin water gauze wet compress, antibiotic drainage strips to fill the wound cavity or the use of l: 5000 potassium permanganate solution sitz bath, although the infection control of the wound has a certain efficacy, but its drainage effect is small, can not achieve the purpose of drainage, or even cause blockage, and easy to lead to the production of wound-resistant strains and metabolic reactions. The dressing change method has no pain relief at the same time of anti-inflammation, and has a certain effect on wound cell growth and wound healing, which makes wound healing slow, and the wound using dressing change is easy to adhere to the dressing and increase the patient’s pain due to mechanical injury again when changing the dressing. The day of anal fistula surgery or the first two days of wound bleeding can be filled with alginate filling strips for drainage, which can play the role of drainage and hemostasis; pus cavity without bleeding, when the infection is not controlled, antibacterial dressings such as silver ion dressing or US salt (hypertonic dressing) can be used for filling and drainage, which not only has good drainage effect, but also can control wound infection and promote wound healing. When the necrotic tissue is loosely adhered to the wound bed, a scraper can be used to scratch the necrotic tissue in the wound cavity; when the necrotic tissue is closely adhered to the wound bed, choose moisturizing dressing for self-soluble debridement.
2.Growth period of granulation
For the 5th to 20th postoperative day, the wound secretion is reduced and the proliferation of granulation tissue is dominant. As the granulation tissue is weak against the stimulation of external physical and chemical factors, it is easily damaged, so this period should focus on protecting the granulation tissue so as not to affect the healing of the wound. The traditional dressing change is to cover the wound with ointment-type drugs to protect the new granulation from external stimulation. Disinfectants should be used sparingly during this period because they not only have an antibacterial effect, but also destroy normal tissues and are detrimental to the growth of the wound. At present, modern wet healing dressings are used after infection control to condition the wound environment and keep it moderately moist to facilitate tissue growth. When the wound exudates a lot, use alginate or hydrophilic fibers and other absorbent dressings, and change them as often as possible according to the amount of exudate, usually once every 1 to 2 days. When the wound cavity becomes shallow and the exudate is reduced, change to hydrocolloid paste such as ulcer paste to fill the wound and cover it with hydrocolloid or foam dressing, and change it once in 3-7 days until it heals. For red granulation but with edema wound choose 50% magnesium sulfate wet dressing or 28% hypertonic salt dressing cover (US salt), edema obviously subsided, good granulation growth wound choose hydrocolloid paste.
3, epithelial migration period
For the 8th to 25th postoperative day. The wound cavity has been filled with granulation tissue. The epithelial cells at the wound edge migrate to the center of the wound and finally cover the wound to make the wound heal. The principle of treatment in this period should reduce the irritation to the wound surface, protect the epithelial growth, and prevent the granulation from overgrowing. It is appropriate to perform intermittent dressing changes with little or no cleaning to protect the surface of the wound. The traditional dressing change is to wrap the wound surface with oil gauze or pearls to reduce inflammatory edema and promote wound healing. The modern method of dressing change is to use hydrocolloid or foam dressing to cover the wound surface, which can make the wound airtight, reduce the chance of infection, maintain the low oxygen status and constant temperature and humidity of the wound, promote the growth of granulation tissue and accelerate the migration of epithelial cells, and facilitate the healing of the wound. Use hydrocolloid dressings or foam dressings, which can be changed once in 5-7 days when there is no shedding or leakage.
The purpose of changing the dressing after anal fistula surgery
1. to remove secretions and feces from the surgical wound to keep the wound clean and prevent contamination and thus infection.
2, the drug gauze placed in the wound during the drug change can not only drain through, but also play a role in protecting the trauma.
3, the change of medication can use some drugs to promote the growth of the wound such as Jiuhua cream, rehabilitation new liquid, etc.
4. facilitating the detection and treatment of unhealthy granulation tissue and promoting wound healing.
5. by filling the gauze strips, it can ensure that the wound healing starts from the base and avoid bridge healing.
6. The elasticity of the rubber band should also be checked for patients with surgical hang-ups, and tightening should be performed if necessary.
In terms of the number of drug changes many patients ask, is it good to change the number of drug changes? The principle is once a day after the stool, early wounds depending on the amount of secretions, but Chinese medicine also has “simmering pus long flesh”, that is to say, secretions on the healing effect of the wound, so the number of drug changes is not the more the better.
All in all, only the proper method of changing medication can be beneficial to wound healing.