Advice needed on seton placement.

Hi everyone,
I am really new to this and once upon a time thought that ignorance was bliss. To sum up from diagnosis (in 2002 or 03) I have been on azathiaprine, infliximab, methotrexate and thats all I remeber but is not the full list!
My perianal fistula first came about approx four years ago but my consultant tried his best to treat with medication rather than surgery (have to admit I was on his side)! However I eventually was referred to a surgeon who has placed a non-cutting seton. When speaking about this procedure he did mention that the fistula was complex and the fitting of the seton was therefore not straight forward. The only mention of cutting came with the consent form on the morning of surgery and the wording was "may require slight cutting". The other part was me consenting to the placement of the seton.
When I awoke in hospital my first concern was to get home and away from the risk of infection. When the surgeon came he informed me I could either stay in for obs or go home. I picked home.
I went away with instructions for the GP nurses on how to pack and dress wound. My first knowledge of size of wound was when the nurse removed 8 inches of packing from my rear end.
The wound started as approx 2 inches in diametre on the outside and approx 2 and a half inches deep. The wound was like a gaping hole that went in all directions not just a tunnel.
The nurses had not seen any procedure like it and either had my doc. I have now been signed off work for another month (initial surgery on Nov 9th) and would just like to know how long others took to heal. I HAD a very active lifestyle and know that I will have to be pretty ship-shape before returning to both jobs.
I also really don't know what the surgeon has done. I imagine (and it looks like) he has actually cut away all the fistula and surrounding tissue and is hoping that the wound will heal quite tightly around the seton.
I have been unable to find out any info like this so am kind of going with just my own thoughts on the matter (and that is never good)!!
I would appreciate any kind of info even if it is just guesses!
Cheers for reading
Plook38

:welcome: Plook! I can not offer advice on the seton as I have never had a fistula, but wanted to welcome you to the forum. We have several people here with experience who will hopefully offer advice. In the meantime - you can hit the search option and there should be some prior threads on the topic as well. Hoping for a speedy and full recovery for you!

Hi Plook-
Your surgery sounds very much like my surgery.
My doc was intending to put in setons, but instead he just scooped it out I guess, and cut right through my anus. Eek! It was sooo painful, but worth it in the end (haha 'in the end'!)
Here is my surgery thread if you want to read it.
http://www.crohnsforum.com/showthread.php?t=2205&highlight=fistula

Welcome to the forum!
MBH

Thanks

Hi again,
Thank you for the link. I have had a read of the stories here and there are some useful bits that I can link to me and mine!
I think I am just so frustrated as I had read that some setons are fitted in day centres without the need to be knocked out at times. I knew I was getting a general and also knew the surgeon had said the fistula was complex but I really thought I had been generous with giving myself a week off work. If only...
I am now looking at three months in total and the worst part is I really don't know how I can go back in another 3 weeks and manage all the duties that are required of me (both jobs are quite active).
My doctor has been only happy to sign me off and even offered morphine for pain at one point. Currently I am taking 8 paracetamol and approx 4 dihydracodeine on a good day. I am able to do most daily tasks but I know all about the 80 yr old shuffle and have just invested in a good bum cushion so that i can do some short car journeys. The only worry is driving whilst on so many tablets!
I still have sore days when I have maybe tried to do too much (still only about a quarter of what I am used too).
It is just so frustrating that a surgeon can play god and perform surgery that hasn't even been explained let alone consented too. If I had thought the recovery would have been half this long I would never have went for it. The fistula drained most days but in actual fact hadn't had painful abcesses for approx 2 years. to see benefits of this surgery will prob take some time as I am a little bitter (if you haven't already noticed)!!
Sorry for the rant but better off out than in I say!
Plook

Gosh that sounds pretty nasty! I hope it heals soon!

Apologies to hijack your thread, but Ive had a seton put in last week and have a similar gaping hole! The nurses are coming twice a day to pack the wound but I was wondering how long it took for you to heal?

Its fustrating for me as I feel really fine and energetic to get back to normal life, but need the wound to be packed to allow healing from the inside out.

Thanks

Hi,

I've had a seton in place for several years and have clocked-up 5 EUAs over the last 12 months. The last procedure ended-up with a very similar result to yours and today is 7 weeks to the day. Still having the wound packed once a day, but it is now a very small ammount and I don't expect to continue for more than another few days.

I took 3 weeks off work this time and I have to say that I'm still in a lot of pain. My job is office based, so not physically demanding. The worst bit is having to sit down much of the day. Recovery seems to depend on how much cutting is done and if packing is used. Some Surgeons use packing, some don't. Based on past experience, packing extends the recovery time, but there does seem to be a better result and less chance of the fistula creating a new branch.

Here's hoping that we are all in more comfort soon!

Mark

It's a bit of a catch 22 for me. My pain is minimal and am feeling fine to go back to work (might be the pred!) But due to the crohn's, need to go for a Number 2 quite often which needs the wound redressed. This would be difficult if I'm at work.

And I don't want to risk putting on a temporary dressing until I can get it repacked just in case it heals over.

Or am I being tooooo cautious?

No I don't think you are being too cautious, keeping the packing in and wound clean are major problems, especially if the opening is very close to the anus. I'm lucky in a couple of respects. Firstly, most of the time my bowels are pretty well controlled so it's routine shit, shave, shower, temporary dressing, off to see the Nurse to get the packing done and then into work. Usually good for the day then apart from changing the top dressing if necessary. Secondly, I'm fully open with my employer, they understand my problem and if needs be I come hope to deal with dressings etc. Of course, this all goes out of the window if the gut does not cooperate! I do have pain, but after six years it's just part of my day to day life now.

I also do the packing my self if necessary. The Nurse provides all the necessary materials and they are amazed at what I can achieve with a mirror and a torch!

Good luck

Mark

Thanks for the advice!

My bowels are not as forgiving and I think the dressing will need to be changed everytime I go for a number 2. But dressing it myself in the evening with a temp solution whilst at work think would do the job.

Unfortunately there is not that much practical info given online or by my nurses. Maybe its because everyone is different!

I've not received any advice at all, just had to work it out for my self. It was suggested that my partner could do it for me, but I said that was not a good idea unless they wanted her ending-up in A&E with a bump on the head from passing out! It was ok untill a couple of weeks ago when I picked-up a bug and was in the toliet on the hour every hour for two days. No sooner had I got cleaned-up than it was time to go again!

Mark

Doh!!!

The best piece of advice I've been given by one of the district nurses was to not to be scared of the showerhead! Everytime I go for a pooh, I jump in the shower and have a good rinse. Pat try with some gauze and pad it until the nurse next comes.

I've let my mum see how to do the dressings just in case but I'm with you. She's not qualified, really scared each time she's had to do it and you can imagine how embarassing it is for me, a 30 yr old single male!

Yes, I forgot to mention the shower head. One of the most vital bits of kit! I also use Hibiscrub to wash the area as water alone in not really effective for the initial clean-up.

Perhaps I should add this to my signature? "I stopped being embarresed about my body six years ago"

Mark, any chance of some descriptive advice?

I'm starting to do the packing myself. Nurse is going to check on my twice a week so she can check the wound, and I can have back a bit of independence.

I'm managing fine. But couple of things. I crouch over a mirror and use forceps to pack. The nurse mentioned I've got to be careful not to pack too much or the wound will get larger and not heal. How do you manage this?

Also, do you use a similar technique? Setup everything to my right, stick on the sterile glove, forcep in the packing, slap on some gauze and sticky pad and good to go.

Hi,

Yes, very similar.

Apart from gloves, most of what you need can be found in a sterile dressing pack (Drug Tariff Spec.No.10). I also have steripods of saline and 10cmx10cm gauze squares. Packing material as required.

After using the shower head and Hibiscrub to clean-up I place a mirror on the bathroom floor and squat over over it. A torch angled up to the area requiring attention provides the necessary illumination.

Carryout a more detailed clean-up with gauze squares and saline. Pat the area dry with more gauze.

Open the packing material, I assume that you are using Calcium Alginate ribbon? Cut off the length that you think is required and use the forceps to lay this into the cavity. You want to fill the cavity, but not pack it tightly. The packing keeps the wound open and allows drainage. The object is for things to heal from the inside out. As a general rule if it feels too uncomfortable after you have carried out this proces, you probably need to have a nother go and not pack it so tightly.

A couple of pieces of gauze are folded and laid on top of the packing followed by the absorbant dressing pad from the pack. The one thing that I don't do is use a sticky dressing or tape to hold things in place, I'm far too hairy for that! I use the very snug fitting net-elastic pants that I beg from the Hospital/Nurse as these are much more comfortable and keep things quite secure.

As things heal-up, you may find it difficult to use forceps and the Alginate rope will get too large. At this point you want to move on to Sorbsan Ribbon which is much narrower and comes with a one time use, plastic probe. The probe has graduation marks that allow you to assess the depth/width of the opening.

I'm now at the point where even the Sorbsan Ribbon is too large, so I cut a strip about 1cm wide off a sheet of Alginate desssing which is very thin and just tuck the end into the hole that has been left adjacent to my Seton.

I'm sure you'll do a good job. It certainly gets easier with practice. I see the Nurse at my GP practice three times a week, just to keep an eye on progress and to pick-up supplies. If I have any problems, I just have to pick the phone up for advice and they will see me the same day if I'm worried about anything.

Hope I've not forgot anything, but if there are more questions then please get back to me. If you need to, then PM me and I'll give you a phone number if you want to talk through things.

Mark

Many many thanks. I feel reassured that Im going something very similar. I think i was a bit rough the first few times but taking it a bit easy now not to make the wound bigger!! Think Ive already made that mistake.

I'm using Aquasel Ribbons at the moment. I was very hairy too but this was my second op in the space of the 2 months and I made it clear to the surgeon to shave as much as he can down there!! He obliged so I can put small dressings on without worrying about the hairll

Thanks for the offer of help and will keep it in mind!