Anal Fistula Surgery: An Overview

Anal fistula surgery has been, in itself, a surgery performed to cure anal fistulas. An anal fistula is a tunnel or passage that forms abnormally inside the anus or rectum, connecting their inner surface to the skin around the anus. The condition could be secondary to an infection or abscess in the anal glands.

The operation begins after selection by the anesthetist to administer anesthesia; it is either given locally or generally, depending on the kind of fistula and the overall state and well-being of the patient. Once the anesthesia has taken full effect, the surgeon starts by checking the location and description of the extent of the fistula. Typically, the surgeon uses an anoscope to examine the area of interest.

Following that, the surgeon will now prepare the opening and perform cleansing, debriding, and sterilizing the area. This action is important to minimize chances of getting an infection during the surgery or after. Once that is done properly, make an incision on the length of a fistula, revealing the whole tract, and then carefully carry on dissecting and removing from the surrounding area.

Depending on the complexity, type, and location of the fistula, sometimes a seton could be left in place to aid in healing in cases where healing may take a longer time. A seton helps in maintaining sutures or a rubber band that is threaded through the fistula track to keep it open and let it drain properly, as well as reducing infection and fluid accumulation of any kind. Depending on when the fistula heals fully, a seton may remain in place for weeks to months.

With the fistula tract totally removed, the surgeon now closes the incision using sutures or stitches, purely depending on the size of the incision and the complexity of the fistula. A dressing would be in place to protect the site and allow for healing after surgery.

After surgery, the patient will be observed for possible complications such as infection or excessive bleeding. Medications may be prescribed to help in managing pain during the first days or weeks of recovery. Follow-up visits will be scheduled to control the healing process and make sure that the anal fistula is properly closed.

In other words, the objective of anal fistula surgery is to destroy this abnormal tunnel and promote healing in the area of those fistulas. Even though the operation is safe and efficacious, following post-op instructions and keeping appointments for follow-up visits with the surgeon are crucial for achieving prompt recovery. It is necessary to have an early treatment of anal fistulas, as this surgery will minimize symptoms and the risk of further complications as a result of the condition.

Types

• Fistulotomy: One of the simplest and most frequently performed procedures for the treatment of anal fistula is fistulotomy. In this procedure, the surgeon effectively incises the entire tract of the fistula, from the internal opening of the anus to the external one situated near the skin. The surgeon then carefully operates on the tract and removes it completely. This technique escorts a successful operation on the fistula, requiring decades of healing. Fistulotomy might not be considered for complex or at-risk fistulas.

• Fistulectomy: This surgical procedure dissects the entire fistula tract and its surrounding tissue. Unlike fistulotomy, which just splits open the tunnel, this technique takes out the entire tunnel. Most people use this procedure to treat complex fistulas or recurrent cases. Fistulectomy requires a longer recovery period than that associated with incontinence compared to other surgical interventions.

• LIFT Procedure: LIFT stands for ligation of the intersphincteric fistula tract. It is a relatively newer technique used to treat complex anal fistulas. In the LIFT procedure, the surgeon makes a small incision in the skin near the external opening of the fistula. Next, the surgeon reaches the intersphincteric space between the anal sphincter muscles, locates the fistula tract, and closes it off. This procedure aims to preserve the sphincter muscles and reduce the risk of incontinence. The LIFT procedure may be preferred in cases where the fistula passes through the sphincter muscles or involves multiple tracts.

Note that the recommended surgery method depends on the fistula's location, complexity, severity, and the patient's functionality and well-being. The surgeon would thus review the factors presented in the patient's condition and propose the kind of treatment that he or she feels is more feasible.

Symptoms

• Persistent Pain: Pain, along with swelling, is one of the distinctive symptoms of an anal fistula. The pain may be extremely severe and can be continuous or acute. Depending on the variant of the fistula, certain individuals experience sharp or aching pain. The pain is exacerbated by prolonged sitting and walking after irritation and swelling induced in surrounding tissues in association with the fistula.

• Bleeding from the Fistula Anus: A constant foul-smelling discharge is considered another hallmark symptom. In particular, the discharge is very off-putting to some patients, who describe it as yellow pus or tinged with blood; this discharge eventually soils clothes.

• Swelling and Redness: The skin at the opening of the fistula may be swollen, very tender to the touch, and red. This inflammation is a natural body response to a local infection or severe irritation. This swelling does make the area uncomfortable and further complicates hygiene.

• Recurring Abscesses: Each subsequent abscess implies the recurrence of the fistula. Abscesses are pockets of pus that begin to form when bacteria infect the anal glands; they are bound to hurt terribly, swell up, and feel hot. It may need medical care.

• Pruritus and Irritation: A compliant patient may also experience these vague or itching feelings; we cannot call themfits, and they will bother the patient in everyday life.

• Changes in Bowel Function: The path of the anal fistula can sometimes make it difficult to have normal bowel movements, leading to episodes of mild to severe diarrhea (incontinence) where you lose feces without meaning to.

Diagnosis

Diagnosis of anal fistula includes:

• Medical History: The doctor will ask about the symptoms, such as mention of pain, discharge, or swelling, or recurrent abscesses in the anal area. A valuable history would include prior treatments and any relevant medical conditions, such as Crohn's disease or an abscess in the anus.

• Physical Exam: The first step in evaluating an anal fistula is for the surgical need specialist to carefully feel the anus area, especially the external opening of the fistula and its skin, for redness, swelling, discharge, or any other problems. They do this by pressing on the area with their examining finger to see if it is deep or moving in any way that doesn't seem right.

• Imaging Studies: Sometimes, to more precisely determine the anatomy of an anal fistula, special imaging studies are required. One of the common imaging modalities could be a fistulogram. In this method, a contrast material is injected into the fistula tract, and X-rays or other imaging tools are used to show its path, branching structures, and opening stage inside the body. Other imaging studies, like magnetic resonance imaging and endoanal ultrasound, may also be suggestive and provide the correct dimensions to assist in diagnosing the fistula along with its surrounding structures.

To get accurate information about a patient's anal fistula, a healthcare provider should look at the patient's medical history, do a physical exam, and look at imaging studies. This information will help them see things like the location, length, and complexity of the anal fistula.

Risks

• Infection: Infection can result from an absence of meticulous care during anal fistula surgery. Infections usually result from the unprevented entry of bacteria into the incision, which leads to infection. The symptoms of infection range from simple increased local pain, redness, warmth, swelling, and discharge. Attention to timely management and treatment of suspected infections may avert the development of complications.

• Bleeding: You should expect some bleeding during and after surgery to treat an anal fistula. Most of this bleeding is minor and is self-limiting. Too much bleeding might necessitate surgical cauterization or the positioning of further sutures to prevent bleeding any further and spare the patient further complications.

• Abscess Formation: There is still a chance of abscess formation after anal fistula surgery, although the objective of surgery is to treat the fistula. Abscess formation can occur as a result of past infections or even a new infection during the post-operative period. Usually, abscesses require further drainage or additional surgical procedures.

• Fistula Recurrence: Healing intent aside, there is still a small chance of recurrence when all subsequent removal surgery on a fistula tract is finished. Factors such as the degree of fistula complexity, the presence of co-existing medical conditions, and any related healing factors pose increased risks for recurrence. Repeat surgery or a different form of therapy may be considered should recurrence occur.

• Fecal Incontinence: While a rare adverse outcome from anal fistulectomy is temporary or permanent fecal incontinence. Associated risk is higher if the fistula involves or affects anal sphincter muscles. Variables include the type of incontinence, such as postoperative incontinence, etc. The operations used should be considered in assessing the relevance, frequency, etc., along with the grade of tissue manipulation during surgery.

• Pain and Discomfort: Pain and discomfort are part of the common experiences of anal fistula surgery. Pain severity varies among individuals, but it is reduced in most people.

Causes

The specific causes of anal fistulas may differ greatly, but here are some points contributing to the formation:

• Anal Abscess: Anal fistulas most always accompany the literal origin of an anal abscess. So, the disease sets in as one of the infected anal glands fills with pus and forms an abscess. The abscess usually stems from bacteria accessing the anal gland via minute tears or blocked ducts. If inadequately drained or treated, the abscess could turn into a fistula.

• Crohn's Disease: Known for chronic inflammatory bowel disease, Crohn's disease predisposes to the development of anal fistulas. In Crohn's disease, the immune system mistakenly targets the digestive tract and causes inflammation. This inflammation can injure the anal glands and thereby cause the formation of fistulas.

• Prior Anal Surgery or Trauma: Former surgery in the anal region or other relevant incidents may increase the chances of an abscess turning into a fistula. Various procedures include hemorrhoidectomy, treating anal fissures, spreading tissues, and many others, which cause damage to the tissue covering the anal canal and may create conditions favorable for a fistula to develop.

• Inflammatory Conditions: Diseases that cause inflammation, such as tuberculosis or sexually transmitted diseases like HIV, result in the weakening of the immune system's abilities to fight off the development of anal fistulas. They lead to severely painful chronic inflammation and rampant tissue-scarring changes, predisposing to an anal fistula.

• Certain Medical Procedures: Several anal procedures frequently intended for another use sometimes culminate in the unforeseen emergence of anal fistulas. For instance, procedures like anal dilatation or sphincterotomy can change normal anatomy out of context, which could lead to a strange connection between the anus (which looks like a demon) and the rest of the body.

• Genetics: The functioning of an anal fistula is hardly known in the medical community. However, some studies indicate that genetic factors may make people more likely to get an infection, have inflammation, or heal improperly, all of which make it more likely that a fistula will form.

Purpose

• Eliminating the Fistula Tract—Complete removal of the fistula tract is the primary objective of anal fistula surgery. This tract is an unnatural passageway that links the inner lining of the anus with the surrounding skin. We remove the tract by sulfonating or stripping it down as much as possible. Such a procedure not only prevents infection, inflammation, and other symptoms but also puts the chosen operative procedures in a healing state.

• Healing Facilitation—Healing an anal fistula can pose many problems, such as infections, most of which would heal only through a surgical process. The surgical excision of the fistula tract ensures a normal healing process for the area. The removal of infected tracts and damaged victim tissues permits the natural healing rate to take over and affect the healing process.

• Prevention of Recurrence—A hydrology of recurrence is commonly observed among untreated anal fistulas. By thoroughly removing the fistula tract from the body, the surgical process aims to minimize this risk. By removing the whole tract and making sure that the fistula is completely removed, the surgery should make it less likely that the fistula will reopen or keep happening.

• Reducing the Symptoms— The severely painful nature of anal fistulas cannot be brushed under the carpet. Discomfort is a hallmark of anal fistulas, often accompanied by discharge, edema, and dysfunctional bowel movements. The surgical process, on the other hand, seeks to reduce these symptoms in pursuit of overall improvement in the quality of life. It focuses on relieving pain, reducing the edema, and controlling the discharge by eliminating the fistula while taking care of the underlying cause.

• Complication Prevention—After medical treatment stops complications from happening, surgery is needed to resolve the problem. Surgery stops complications like abscesses, chronic infections, anal strictures, and fecal incontinence from getting worse. Thus, the main goal is to restore the proper function of the anal passage and circumvent further medical complications.

Seek advice from a healthcare professional to determine the most suitable surgical treatment for anal fistula.

Procedure & Recovery

Surgery:

• Anesthesia: Prior to the surgery, the patient should be under anesthesia to relieve discomfort. The type of anesthesia will vary depending on the complexity of the fistula and overall patient fitness. Anesthesia may be anything from local anesthesia, in which case only the area is noxious, to general anesthesia, in which case sleep initiates.

• Fistula Tract Examination: By the time anesthesia takes effect, the doctor, using an anoscope, examines the visible part of the rectum to determine the extent of the tract.

• Cleaning and Preparation: Cleaning the area around the fistula prepares it for the procedure. This is done to reduce the risk of infection during the surgery and its aftermath. Most surgeons apply sterilizing solutions to the area and may choose to prescribe antibiotics.

• • Incision and Tract Excision: After making an incision along the fistula tract's length, we will fully identify and dissect it. We must pay special attention to preserving the surrounding structures and preventing damage.

• • Seton insertion (if required): If the parameters of this fistula treatment warrant it, we may insert a seton. We place a seton, a piece of suture or rubber band, through the fistula tract. A seton eases the drainage of fluid and infection from the fistula while keeping it open. Typically, we leave the seton in place for the specified period to aid in the healing process.

• Closure: Finally, after cutting the fistula tract into sections, the cut is carefully closed with sutures or stitches, depending on the size and technical difficulty of the fistula. Closing techniques aim to promote proper and safe healing while preventing wound infection.

Recovery:

• Managing Pain: Invariably, there will be pain and discomfort following anal fistula surgery. Pain medications are prescribed by the doctor to manage the pain and offer relief during the recovery period. The patient is required to follow the given guidelines about pain management to ensure a smooth recovery.

• Wound Care: For proper healing and the prevention of infection, wound care is essential. Therefore, please follow the doctor's instructions to keep the wound clean and dry. This care usually involves sitz baths, the application of mild soap, or the dressing of the wound with accordingly prescribed ointments.

• Activity and Rest: During the recovery state, regulate periodic movements in an equal manner. The more strenuous the movement, the better. Lighter movements such as walking or gentle stretching are beneficial as they improve circulation and reduce the risk of complications.

• Diet and Bowel Movements: While in recovery, avoid constipating foods or drinks that would strain one's bowel movements, which could lead to hostility in the area of operation. We may advise the patient to drink plenty of liquids and maintain a fiber-rich diet to prevent undesirable postoperative outcomes.

• Follow-Up Care: Regular follow-up treatment is highly advisable for the management of healing status, suture removal necessities, and answering any concerns or complications should they arise.

In most cases, recovery time varies from patient to patient, but most people recover slowly over several weeks.

Preparation

Several preparations need to precede anal fistula surgery to ensure that it occurs safely and successfully.

Before surgery, we will conduct a thorough medical evaluation. This type of evaluation usually includes a history of a previous medical examination, physical examination, and sometimes laboratory analyses. The idea of the evaluations is to assess your general health to find out if you have any previous medical problems that could influence the surgery, to identify the anesthesia approach most befitting the patient, and to share information about expectations of surgery, such as risks and benefits.

• Preoperative instructions: Adhere to the prescribed medicines, as the doctor will provide specific preoperative instructions a few days before surgery. The directions may include fasting, restrictions on food and water consumption before surgery, and medications that are necessary for adjustment. Adhering to these directions will reduce the risk of complications from surgery.

• Drug management: Please inform your doctor of all medicines, both prescribed and over-the-counter medications, and any daily supplements you may be presently taking. Some drugs may be altered in dosage or stopped temporarily in the interest of surgery, especially those that increase the probability of bleeding and those that interact with anesthesia.

• Consent: Your surgeon explains the benefits and risks of the anal fistula operation. Your surgeon informs you about the procedure, its purpose, and the expected outcome. This knowledge helps you decide if anal fistula surgery is best for you. Signing a form indicates your understanding and agreement to the anal fistula operation, known as informed consent.

• Your surgeon may recommend some lifestyle changes before your surgery, depending on your specific situation. The modifications may include dietary changes for adequate laxation and less constipation, such as eating more fiber and drinking more water. Your surgeon may also instruct you to avoid behaviors that may exacerbate your condition—for example, sitting too long or engaging in heavy exercise.

• Having a support system is crucial when preparing for anal fistula surgery. To accomplish this, explain the procedure to a trusted relative or friend who can provide you with surgery information. They can be present for any kind of assistance you may need, from getting you to the hospital to laming you up at home post-surgery.

Clinical Trials

We use research studies called clinical trials to determine the safety and effectiveness of new treatments, interventions, or surgical techniques. This scenario includes surgery for anal fistula. Trials are usually designed to collect scientific data and provide scientific evidence to support improvements in the way we care for the patients or health outcomes. For anal fistula surgery, these clinical trials could be used to test new surgical techniques, advanced technologies, treatment options, and different ways to care for patients after surgery.

One benefit of participating in a clinical trial on anal fistula surgery is that patients can access new treatments or operations not otherwise available to them. Participation in the study lets patients avail themselves of novel surgical techniques and other novel approaches to managing anal fistulas.

Clinical trials also play a significant role in closely monitoring postoperative follow-up through a multidisciplinary group of healthcare providers. Such data can greatly personalize patients' care toward this population and their journey to surgical management.

Moreover, being a part of a clinical trial can lead to a new area of knowledge. Thus, enrolling in a trial will allow you to actually become part of the test data and thereby enable researchers to sculpt future medications aimed at treating anal fistulas and improving the quality of patient outcomes. While participating, patients can help develop various research on evidence-based guidelines and recommendations, which might be of assistance to others with like conditions.

However, there are some risks and things to think about when you decide to take part in a trial. These can include unknown side effects, delays in treatment, or the chance of getting a placebo or a different treatment that doesn't work as well as the usual method. People who are contemplating enrolling in a clinical trial will need to take the time to understand the purpose, design, risks, and potential benefits of participating in the trials. Consulting with the medical team and going through the informed consent document is a crucial factor for those willing to make an informed decision about participating in the clinical trial.

Clinical trials play an important role in furthering medical knowledge and improving patient care-possibilities. They offer a chance to test new treatments or ideas to elevate the sense of anal fistula surgery and improve outcomes and quality of life for those with such a condition.

Anal fistula surgery in India

In India, anal fistula surgery is necessary. India has a fantastic system of health services, comprising many medical care units and hospitals with advanced technology and skilled surgeons. Expert surgeons are found everywhere in India, where surgeries are largely given attention.

The country prides itself on offering high-quality health care services to its populace and foreigners. These are well-equipped with modern infrastructures, including surgeries with advanced technological features and support from a highly skilled and devoted surgical team managing surgeries on fistulas of any nature.

Determining the relatively lower cost of anal fistula surgery in India is among the greatest advantages. Treatments for ailments in India are more cost-efficient compared to those in other countries. This, in turn, makes it a center worthy of considering for those in search of cost-effective medical solutions without compromises over quality.

Cost in India

The cost of anal fistula surgeries in India could be more variable, subject to the clinic or hospital's name, surgeon's seniority, and the complexity of the fistula contributed by that technique and hospital region of India. However, it is known that anal fistula surgery in India is relatively cost-efficient as compared to most other countries.

The estimated costs associated with anal fistula surgery in India are diverse, and they include pre-operative assessment fees, surgeon's fees, anesthesia, hospital stay, hospital charges, medications, postoperative care, and follow-up charges. New possibilities might also impose additional charges on the patient in cases where one unexpectedly ends up in the hospital without healthy days following recovery, compared to previously established examinations.

Costs for anal fistula surgery in India may range between $800.00 and $3000.00, based largely on the series of factors addressed before. In fact, these estimations are just appraisals and tend to vary dramatically from one healthcare facility to the next.

One more big contributor to reduced surgery costs is how, generally, healthcare services apart from anal fistula surgery are far less costly on the Indian health patcher. Indeed, the costs of surgical tests, hospital administration, and surgical equipment in India are significantly lower than those of similar organizations in Europe, the United States, and certain parts of Asia.

While offering more excellent possibilities to patients coming from abroad, the currency rate is a beneficial means of making every one of the medical treatments here cheaper for an international client population. Patients might take full advantage when they convert rands to Indian rupees, thereby lessening the costs to the fullest.

However, the price should not be the only consideration while selecting a healthcare provider for anal fistula surgery. Cost and quality should always complement each other. The standard of psychiatric attention, the reputation of the clinic or hospital in place, the history of treatment experienced by the surgical team, the modern facilities, and the availability of modern medical equipment must also be considered high stakes.

In every form of the research, gather bits to savor. And give preference to visiting a host of dependable sources of information who can direct you with the perfect answer for moving on with your treatment needs in India. Simultaneously, patients should take their time to learn more about the advantages of the services and their associated costs, regardless of any uncertainties they may encounter in a health care center or hospital. Making those inquiries helps the patients decide whether the worth of the service matches the cost of the medical treatment.

Many hospitals and clinics in India offer international patient services, enabling them to assist foreign patients with their air travel requirements, accommodations, and visa processing. These are all factors that, in the long run, help to shorten the procedures and ensure a very smooth experience for the patient coming from elsewhere.

Side Effects

The first few days after the anal fistula surgery can be challenging due to the associated discomfort or pain. Typically, the discomfort ranges from mild to moderate, and it usually subsides with time. There are various pain medications that the surgeon is going to prescribe for curtailing such discomfort during recovery.

• Bleeding: Bleeding from an anal fistula surgical site is a completely normal thing. Most of the minor bleeding cases are going to stop by themselves. Eventually, severe or heavy bleeding may occur, necessitating significant measures to prevent further worsening. Hence, the doctor's intervention is crucial in case the situation persists or is in danger!

• Infection: Surgical procedures demand a sane, germ-free atmosphere, but invariably infection might affect a site post-operation. Signs of infection include increased pain, redness, warmth, or discharge from the site. One should seek help from a doctor promptly upon pinpointing any of these signs rather than taking matters into their hands.

• Incontinence: The thing is that when the anal sphincter muscle gets injured, sometimes involuntarily, there is always an empathetic focus on post-operative recovery with limited or total fecal incontinence. Talk to your surgeons about the odds and risks in your case.

• If the goal of surgery for an anal fistula is to close the entire fistulous tract, it may return due to complexity, other health issues, or healing issues. To eliminate these recurrences, an appropriate surgical approach must be considered, or such instances can either be medically managed or surgically.

• Scarring and Healing Wounds: They may make cuts and sew up wounds, which means that scarring will appear depending on things like the type of procedure or the level of tissue reaction, which is one of the things that will affect the level of scarring. Scrutiny of patients as per the mandatory monitoring of scars, according to the instructions provided post-operatively by the surgeon, will be beneficial for a comprehensive healing of wounds.

• Bowel Habit Changes: Sometimes, anal fistula surgery can change your bowel habit temporarily, from diarrhea to constipation, or vice versa. This problem is often self-resolving as the body tries to adapt and heal. However, persistent or severe cases should prompt a discussion with a surgeon.

All open communication between the care professionals and yourself regarding any concerns or side effects related to anal fistula surgery is critical. The likelihood is that such side effects will be low; however, understanding them and managing them correctly will guarantee a healthy recovery and ultimately good results.

Success Rate

The success rate of anal fistula surgery is generally high, with several patients eventually experiencing relief from symptoms and getting a favorable operation. The outcome depends on various factors, including the type, complexity, technique, surgeon skill, and patient health.

The success rates in simple fistulas, such as low-degree or superficial fistulas, are pretty high in the surgery system. Procedures like fistulotomy or fistulectomy have displayed high success rates in addressing these types of fistulas. These surgeries involve the complete removal of the fistula tract and allow for the closure of the wound.

But success rates may be different in cases that are more complicated or dangerous, like when there are multiple tracts, when they cross the anal sphincter muscles, or when there is an underlying condition like Crohn's. Such conditions may necessitate more advanced surgical techniques like LIFT or sphincter preservation techniques to give a healthy outcome yet have the smallest chance of complications.

Importantly, the post-surgical care and responsibilities that lie with the patient will ultimately determine the degree of success of the surgery. Proper wound care, compliance with medication, and attendance at follow-up visits have to be strictly observed to monitor the healing progress and deal with the resolution of consequent side effects.

After surgery for an anal fistula, the success of the procedure is determined by how well the wound heals, how well the pain, discharge, and swelling go away, and how well the anal functions return to normal. While most patients do well, it's important to remember that outcomes vary.

Diet

The anal fistula surgery is a surgical technique that is used for the treatment of anal fistula. It involves the formation of a small tubelike organization that extends from the surrounding skin to the inside of the anal canal. This condition usually results from the failure of an anal abscess to heal properly. Diet is important postoperatively, but it won't cure the anal fistula by itself.

Maintaining a healthy diet after an anal fistula surgery is crucial for promoting healing and preventing complications. A fibrous diet is an effortless option to work with—the more fiber you have, the softer your stools are, which means fewer problems with constipation, which would cause a considerable amount of strain on the wound, impairing healing. Among the classical sources of fiber are grains, fruits, vegetables, and legumes.

At the same time, we must remember to drink many fluids, particularly water, to keep ourselves well-fed and soft and to prevent excessive straining during bowel movements. Avoid sodas, coffee, and juices, as they can possibly result in nothing but dehydration and irritation of the digestive tract.

Dietary sources of repair and wound healing proteins are crucial in a balanced diet, for proteins come in the form of lean meats, fish, poultry, eggs, dairy, and plant sources like legumes and beans. Besides producing all the proteins needed to build the body, it must get enough from its diet.

The best bet, of course, is to avoid some of the following dishes post-surgery to help limit discomfort and minimize the possibility of runner-up complications. Spicy foods, oily and fast foods, and too much sugar need to be taken off or cut from the diet since, eventually, they often simply aggravate the gut lining.

To begin with, be careful to observe the dietary guide and advice from the surgeon after surgery and finish up all prescribed medications. It is necessary to return for regular check-ups and closely monitor the healing and, if need be, make adjustments to the diet and treatment.