Garg P, Yagnik VD, Dawka S, Kaur B, Menon GR. Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator, suprasphincteric, extrasphincteric, high outersphincteric, and high intrarectal fistulas. World J Gastroenterol 2022; 28(16): 1608-1624 [PMID: 35581966 DOI: 10.3748/wjg.v28.i16.1608]
Corresponding Author of This Article
Pankaj Garg, MD, MS, Chief Surgeon, Department of Colorectal Surgery, Garg Fistula Research Institute, 1042/15, Panchkula 134113, Haryana, India. drgargpankaj@yahoo.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Therapeutic and Diagnostic Guidelines
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastroenterol. Apr 28, 2022; 28(16): 1608-1624 Published online Apr 28, 2022. doi: 10.3748/wjg.v28.i16.1608
Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator, suprasphincteric, extrasphincteric, high outersphincteric, and high intrarectal fistulas
Pankaj Garg, Vipul D Yagnik, Sushil Dawka, Baljit Kaur, Geetha R Menon
Pankaj Garg, Department of Colorectal Surgery, Garg Fistula Research Institute,Panchkula 134113, Haryana, India
Pankaj Garg, Department of Colorectal Surgery, Indus International Hospital,Mohali 140201, Punjab, India
Vipul D Yagnik, Department of Surgical Gastroenterology, Nishtha Surgical Hospital and Research Center, Patan 384265, Gujarat, India
Sushil Dawka, Department of Surgery, SSR Medical College, Belle Rive 744101,Mauritius
Baljit Kaur, Department of Radiology, SSRD Magnetic Resonance Imaging Institute, Chandigarh 160011, India
Geetha R Menon, Department of Statistics, Indian Council of Medical Research,New Delhi 110029, India
Author contributions: Garg P conceived and designed the study, collected and analyzed the data, revised the data, approved and submitted the final manuscript (guarantor of the review); Dawka S critically analyzed the data, reviewed and edited the manuscript, and approved and submitted the final manuscript; Kaur B and Yagnik VD collected and analyzed the data, revised the data, and approved and submitted the final manuscript; Menon GR analyzed the data, revised the data, and approved and submitted the final manuscript.
Conflict-of-interest statement: None of the authors, Pankaj Garg, Vipul D Yagnik, Baljit Kaur, Sushil Dawka, or Geetha R Menon, have any conflict of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Pankaj Garg, MD, MS, Chief Surgeon, Department of Colorectal Surgery, Garg Fistula Research Institute, 1042/15, Panchkula 134113, Haryana, India. drgargpankaj@yahoo.com
Received: August 25, 2021 Peer-review started: August 25, 2021 First decision: September 29, 2021 Revised: October 6, 2021 Accepted: March 16, 2022 Article in press: March 16, 2022 Published online: April 28, 2022 Processing time: 241 Days and 17.7 Hours
Abstract
Supralevator, suprasphincteric, extrasphincteric, and high intrarectal fistulas (high fistulas in muscle layers of the rectal wall) are well-known high anal fistulas which are considered the most complex and extremely challenging fistulas to manage. Magnetic resonance imaging has brought more clarity to the pathophysiology of these fistulas. Along with these fistulas, a new type of complex fistula in high outersphincteric space, a fistula at the roof of ischiorectal fossa inside the levator ani muscle (RIFIL), has been described. The diagnosis, management, and prognosis of RIFIL fistulas is reported to be even worse than supralevator and suprasphincteric fistulas. There is a lot of confusion regarding the anatomy, diagnosis, and management of these five types of fistulas. The main reason for this is the paucity of literature about these fistulas. The common feature of all these fistulas is their complete involvement of the external anal sphincter. Therefore, fistulotomy, the simplest and most commonly performed procedure, is practically ruled out in these fistulas and a sphincter-saving procedure needs to be performed. Recent advances have provided new insights into the anatomy, radiological modalities, diagnosis, and management of these five types of high fistulas. These have been discussed and guidelines formulated for the diagnosis and treatment of these fistulas for the first time in this paper.
Core Tip: These are the first published guidelines to manage the five types of peri-levator anal fistulas that involve almost the complete external anal sphincter and have, therefore, been grouped together as high-5 fistulas. These are supralevator, suprasphincteric, extrasphincteric, and high intrarectal and fistulas at the roof of ischiorectal fossa inside the levator ani muscle. The diagnosis and management of these five fistulas is quite challenging. Magnetic resonance imaging is the best modality to accurately delineate these fistulas. Once diagnosed, care should be exercised to avoid sphincter-cutting procedures (fistulotomy) in these fistulas, as the risk of incontinence would be very high. Sphincter-sparing procedures should be done. However, there is little literature available on satisfactory management of these fistulas.
