Successful Fistulectomy for Perianal Fistula in a 67 Y.O. Male with Multiple Comorbidities

Chief Complaints

A 67-year-old male patient with a body mass index (BMI) of 20 presented to the Surgical Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of intermittent pus and bloody discharge from the perianal region for the past six months. He also reported pain following defecation. The symptoms were recurrent in nature and were not associated with fever or abdominal pain.

The patient was a known case of Hypertension and was on regular treatment. He also had associated comorbidities, including Dyslipidemia and Meralgia Paresthetica (burning thigh pain), for which he was under medical management. There was no documented history of diabetes mellitus, major abdominal illnesses, or prior similar anorectal surgeries.

On examination, the patient was conscious, coherent, oriented, and with stable vitals. Systemic examination revealed normal cardiovascular findings with normal heart sounds. Respiratory system examination showed adequate bilateral air entry. Abdominal examination was soft with no tenderness. Central nervous system examination did not reveal any focal neurological deficits.

Upon admission to PACE Hospitals, the patient was thoroughly evaluated by the Surgical Gastroenterology team. He presented with complaints of intermittent pus and bloody discharge from the perianal region for six months, associated with pain following defecation. There was no history of fever or abdominal pain. Clinical assessment and history were suggestive of a fistula in Ano.

The patient underwent further diagnostic evaluation. MRI fistulogram revealed a long, complex fistulous tract in the left perineal region with intersphincteric extension and associated branching tracts with a small collection. Histopathological examination of the excised tissue showed granulation tissue consistent with a fistulous tract and was negative for granulomas. Routine laboratory investigations, including complete blood picture, liver function tests, renal function tests, blood sugar levels, lipid profile, thyroid profile, and urine examination, were performed. Most parameters were within normal limits, with notable findings including low vitamin D levels, borderline glycemic status, mild eosinophilia, and low HDL cholesterol. Imaging of the abdomen revealed grade I fatty liver changes. Cardiac evaluation showed preserved cardiac function with mild diastolic dysfunction.

Based on the confirmed diagnosis, the patient was advised to undergo Anal Fistula Treatment in Hyderabad, India, under the expert care of the Surgical Gastroenterology Department, to remove the fistulous tract, control infection, relieve symptoms, and prevent recurrence, thereby improving overall quality of life.

After a detailed consultation with the surgical gastroenterologist Dr. Suresh Kumar S, along with the General physician Dr. Mounika Jetti, a comprehensive clinical and radiological evaluation was carried out to determine the most appropriate management plan for the patient.

Based on the patient’s presenting complaints of chronic intermittent pus and bloody discharge from the perianal region associated with pain during defecation, along with MRI fistulogram findings confirming a complex fistulous tract with branching, a diagnosis of fistula-in-ano was established. Considering the chronicity of symptoms, anatomical extent of the tract, and risk of recurrent infection, surgical intervention was deemed necessary.

It was determined that fistulectomy was identified as the most appropriate treatment to completely excise the fistulous tract, promote healing, and prevent recurrence. The patient was also evaluated for associated comorbidities including hypertension, dyslipidemia, and meralgia paresthetica, and was optimized medically prior to surgery.

The patient and his family members were counselled in detail regarding the diagnosis, the need for surgical management, the procedure involved, potential risks and complications such as recurrence, infection, and delayed wound healing, as well as the expected postoperative recovery and wound care, including sitz bath. 

Following the decision, the patient was scheduled for Fistulectomy Surgery in Hyderabad at PACE Hospitals under the expert care of the Surgical Gastroenterology Department.

The procedure involved the following steps:

• Anesthesia and Positioning: The patient was administered appropriate anesthesia (spinal or general) and positioned in lithotomy or prone jackknife position to allow adequate exposure of the perianal region. The operative field was cleaned and draped under sterile conditions.

• Identification of Fistulous Tract: The external opening of the fistula was identified in the left perineal region, and the tract was assessed using gentle probing and/or dye injection to delineate its course and internal opening.

• Exposure and Incision: An elliptical incision was made around the external opening, and dissection was carried out carefully along the fistulous tract, exposing its full extent through the subcutaneous and intersphincteric planes.

• Excision of Fistulous Tract: The entire fistulous tract, including all branches and extensions as identified on imaging, was completely excised up to the internal opening, ensuring removal of all infected and granulation tissue.

• Hemostasis and Wound Care: Meticulous hemostasis was achieved, and the surgical cavity was left open or partially dressed to allow healing by secondary intention. A sterile dressing was applied, and the patient was shifted to recovery for post-operative care.

The procedure was uneventful, and the patient was closely monitored during the postoperative period. During the hospital stay, he was managed with appropriate medications for pain control, wound healing, neurological symptoms, and prevention of infection. Regular sitz baths were given along with wound care.

In view of bilateral lower limb paresthesia, a neurologist's opinion was obtained, and their advice was duly followed. Histopathological examination of the excised tissue showed granulation tissue consistent with a fistulous tract and was negative for granulomatous disease. The patient remained hemodynamically stable throughout the post-operative period without any complications and showed satisfactory clinical improvement. He was subsequently discharged in stable condition.

Upon discharge, the patient was prescribed medications for gastric protection and for infection prevention and wound healing. He was also given treatment for post-operative pain control, inflammation reduction, and to support recovery. The patient was continued on regular therapy for blood pressure control and management of dyslipidemia. In view of bilateral lower limb paresthesia, medications were prescribed for neuropathic pain management.

The patient was advised to continue sitz baths regularly, maintain adequate oral fluid intake, and follow a soft diet as part of post-operative care and recovery.

The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as fever, abdominal pain, vomiting, or any bleeding manifestations.

The patient was advised to follow up with the surgical gastroenterologist in Hyderabad at PACE Hospitals and also to review with the General Physician after 30 days, along with CBP, LFT, and RFT reports, with prior appointment.

This case highlights a diagnosis of fistula in ano managed with MRI evaluation followed by surgical fistulectomy. The postoperative course remained uneventful with good clinical recovery and no complications. Associated comorbid conditions were managed appropriately during the hospital stay. The case concluded with the patient being discharged in a stable and satisfactory condition.