Hello, thanks for your call today. I just had a look at the patient Mr. Yang’s medical history in our hospital, and according to that, he initially came to the hospital on 15 May for a hemorrhoidectomy and was discharged on 23 May. However, he returned to the hospital for a consultation on 1 June, with lumbosacral pain accompanied by mild fever. The digital rectal examination revealed a lump with tenderness and a waving feeling around his anus. He was diagnosed with ischiorectal abscess through anoscopy. The patient then received surgical treatment: an incision close to the anal verge was made for drainage and evacuation of the pus.  A small opening was left in the skin of the affected area after the operation to allow any residual pus to drain quickly. The patient stayed in the hospital for the drainage for about five days. During the week, he…er… was offered a warm herbal sitz bath every night followed by cleaning of the draining by our nurses on the ward.

Well, a week after, the patient complained of swelling, pain and itchiness in the anal area and having mucus mixed with his stool. A final diagnosis of a high-level trans-sphincteric fistula was made through digital rectal examination, probe, ultrasound and MRI: the track crossed the external sphincter and then divided into an upper arm that reached the apex of the ischioanal fossa but not yet passed through the levator ani muscles into the pelvis, and a lower arm that extended to the perineal skin. After the diagnosis, the patient received an operation where a seton was inserted after the skin and anal canal mucosa between the external opening and the internal opening was incised to preserve both external and internal sphincters. To allow the patient to adjust the tension for minimal discomfort, a No. 1 nylon suture was threaded around the sphincter and tied loosely followed by a heavy elastic band secured to the suture and a safety pin was attached. The pin was then taped to the thigh with a small amount of tension. A small portion of the tract was excised and sent for pathologic examination to rule out Crohn’s disease.

After the procedure, the patient stayed in hospital for about a month and the wounds were managed by daily digitation and irrigation. The postoperative manometric evaluation and anorectal function were normal. No faecal incontinence was noted but occasional poor control of flatus was observed. The plan was to have the seton drainage placed for long-term, well, at least three to six months, before performing fistulotomy. However, after three months, we noticed that there was a secondary opening above the puborectalis muscle due to the chronic infection of the anal gland and we proposed performing endorectal mucosal advancement flap to the patient, but he refused it. I explained to him that he would require fistulotomy to eliminate the seton and the fistula in the future, and he told me that he would go back to Australia to have the procedure because he felt very depressed during the long stay in hospital. His full blood counts were normal except the haemoglobin level was a bit low during admission. I can send his pathology results through if needed. Do you have any other questions?