Retrospective Cohort Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Apr 27, 2021; 13(4): 340-354
Published online Apr 27, 2021. doi: 10.4240/wjgs.v13.i4.340
Lessons learned from an audit of 1250 anal fistula patients operated at a single center: A retrospective review
Pankaj Garg, Baljit Kaur, Ankita Goyal, Vipul D Yagnik, Sushil Dawka, 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
Baljit Kaur, Department of Radiology, SSRD Magnetic Resonance Imaging Institute, Chandigarh 160011, Chandigarh, India
Ankita Goyal, Department of Pathology, Gian Sagar Medical College and Hospital, Patiala 140601, 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
Geetha R Menon, Department of Statistics, Indian Council of Medical Research, New Delhi 110029, New Delhi, India
Author contributions: Garg P conceived and designed the study, collected and analyzed the data, and revised the data (Guarantor of the review); Kaur B, Goyal A and Yagnik VD collected and analyzed the data, and revised the data; Dawka S critically analyzed the data, reviewed, and edited the manuscript; Menon GR analyzed and revised the data; All authors finally approved and submitted the manuscript.
Institutional review board statement: The study was reviewed and approved by the Indus International Hospital-Institute Ethics Committee (approval number EC/IIH-IEH/SP6).
Informed consent statement: All study participants or their legal guardian provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author, Pankaj Garg at drgargpankaj@yahoo.com.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
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: http://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: December 28, 2020
Peer-review started: December 28, 2020
First decision: January 18, 2021
Revised: January 18, 2021
Accepted: March 29, 2021
Article in press: March 29, 2021
Published online: April 27, 2021
Processing time: 112 Days and 21.1 Hours
Abstract
BACKGROUND

A complex anal fistula is a challenging disease to manage.

AIM

To review the experience and insights gained in treating a large cohort of patients at an exclusive fistula center.

METHODS

Anal fistulas operated on by a single surgeon over 14 years were analyzed. Preoperative magnetic resonance imaging was done in all patients. Four procedures were performed: fistulotomy; two novel sphincter-saving procedures, proximal superficial cauterization of the internal opening and regular emptying and curettage of fistula tracts (PERFACT) and transanal opening of intersphincteric space (TROPIS), and anal fistula plug. PERFACT was initiated before TROPIS. As per the institutional GFRI algorithm, fistulotomy was done in simple fistulas, and TROPIS was done in complex fistulas. Fistulas with associated abscesses were treated by definitive surgery. Incontinence was evaluated objectively by Vaizey incontinence scores.

RESULTS

A total of 1351 anal fistula operations were performed in 1250 patients. The overall fistula healing rate was 19.4% in anal fistula plug (n = 56), 50.3% in PERFACT (n = 175), 86% in TROPIS (n = 408), and 98.6% in fistulotomy (n = 611) patients. Continence did not change significantly after surgery in any group. As per the new algorithm, 1019 patients were operated with either the fistulotomy or TROPIS procedure. The overall success rate was 93.5% in those patients. In a subgroup analysis, the overall healing rate in supralevator, horseshoe, and fistulas with an associated abscess was 82%, 85.8%, and 90.6%, respectively. The 90.6% healing rate in fistulas with an associated abscess was comparable to that of fistulas with no abscess (94.5%, P = 0.057, not significant).

CONCLUSION

Fistulotomy had a high 98.6% healing rate in simple fistulas without deterioration of continence if the patient selection was done judiciously. The sphincter-sparing procedure, TROPIS, was safe, with a satisfactory 86% healing rate for complex fistulas. This is the largest anal fistula series to date.

Keywords: Anal fistula; Fistulotomy; Incontinence; Surgery; Recurrence

Core Tip: This is the largest anal fistula study reported to date, with 1351 procedures performed in 1250 patients over 14 years at an exclusive fistula-care center. A treatment algorithm was consistently followed. Fistulotomy was done for simple fistulas, and a novel sphincter-sparing procedure, transanal opening of intersphincteric space, was performed for complex high fistulas. The overall success rate was 93.5% in all fistulas, 98.6% for simple fistulas, and 86% in complex high fistulas. Fistulas associated with abscesses were managed safely and successfully by definitive surgery on the first attempt . Several novel concepts were developed during the study.