Garg P, Kaur B, Goyal A, Yagnik VD, Dawka S, Menon GR. Lessons learned from an audit of 1250 anal fistula patients operated at a single center: A retrospective review. World J Gastrointest Surg 2021; 13(4): 340-354 [PMID: 33968301 DOI: 10.4240/wjgs.v13.i4.340]
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
Surgery
Article-Type of This Article
Retrospective Cohort Study
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 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
ARTICLE HIGHLIGHTS
Research background
Anal fistula is a disease dreaded by both patients and surgeons because the treatment of complex fistulas is very challenging. The two main challenges are high risk of recurrence and damage of the anal sphincters that leads to loss of control over bowel motions (anal incontinence).
Research motivation
An effort was made to manage anal fistulas with a high success rate and minimum loss of continence.
Research objectives
To develop sphincter-sparing procedures to manage high complex anal fistulas. Apart from being sphincter-saving, these procedures should also have high healing rates.
Research methods
Two innovative sphincter-sparing procedures, transanal opening of intersphincteric space (TROPIS) and proximal superficial cauterization of the IO and emptying regularly of fistula tracts and curettage of tracts (PERFACT) were developed. The results achieved with the use of those two procedures in high complex fistulas were evaluated. The results of fistulotomy in low fistulas AFP procedures performed in early phase of the study were also analyzed.
Research results
AFP procedures had very low healing rates (19%); fistulotomy had a very high success rate (98.6%) with minimal loss of incontinence. However, the patient selection had to be done judiciously. Garg classification was extremely helpful in identifying patients suitable for fistulotomy. In high complex fistulas, the PERFACT procedure had a good 86% success rate initially but it declined to 50% during long-term follow-up. The TROPIS procedure had a reasonably high 86% success rate with insignificant risk to continence in high complex fistulas even on long-term follow-up. TROPIS thus became the procedure of choice for high complex fistulas at our center.
Research conclusions
Fistulotomy leads to excellent results in low fistulas and TROPIS leads to reasonably high healing rates in high complex fistulas. The risk of continence is minimal if patient selection is done appropriately using the Garg classification.
Research perspectives
Future research should focus on improving the TROPIS procedure and developing innovative sphincter-saving procedures that have even better success rates in high complex anal fistulas.
