Lessons learned from an audit of 1250 anal fistula patients operated at a single center: A retrospective review

Figure 1 Timeline of the surgical procedures done at the Garg Fistula Research Institute over a 14-year period. PERFACT: Proximal superficial cauterization of the internal opening and emptying regularly of fistula tracts and curettage of tracts; TROPIS: Transanal opening of intersphincteric space.

Figure 2 Garg Fistula Research Institute algorithm for the management of anal fistula patients. MRI: Magnetic resonance imaging; TROPIS: Transanal opening of intersphincteric space.

Figure 3 A 35-year-old male patient with a suprasphincteric anal fistula managed by transanal opening of intersphincteric spaceprocedure. A: Axial section (Schematic diagram); B: Coronal section (Schematic diagram); C: Preoperative photograph; D: Preoperative T2-weighted magnetic resonance image (MRI) axial section; E: T2-weighted preoperative MRI coronal section; F: Postoperative photograph showing the transanal opening of intersphincteric space wound, the laid open intersphincteric portion of the fistula tract, in the anal canal; G: Postoperative T2-weighted MRI axial section 3 mo after surgery showing healed fistula tracts; H: Postoperative T2-weighted MRI coronal section 3 mo after surgery showing healed fistula tracts; I: Postoperative photograph showing the final picture and a tube inserted in the tract in right ischiorectal fossa. The tube was sutured to the skin with monofilament non-absorbable 2-0 nylon. Orange arrows show fistula tracts.

Figure 4 A 30-year-old male patient with a recurrent high transsphincteric horseshoe anal fistula with supralevator extension treated with transanal opening of intersphincteric space procedure. There was no external opening. A: Axial section (Schematic diagram); B: Coronal section (Schematic diagram); C: Preoperative photograph; D: T2-weighted MRI low level axial section showing the intersphincteric horseshoe tract; E: Postoperative t2-weighted MRI high level axial section showing supralevator rectal opening at 9 o’clock (Blue arrow); F: Postoperative photograph showing the transanal opening of the intersphincteric space wound, the laid open intersphincteric portion of the fistula tract, in the anal canal; G: Postoperative T2-weighted MRI low level axial section showing healed fistula tracts 3 mo after surgery; H: Postoperative T2-weighted MRI high level axial section showing healed supralevator fistula opening 3 mo after surgery (Blue arrow), and I: Postoperative photograph showing the final picture. The low tract was laid open from the external opening at 7 o’clock and internal opening at 6 o’clock. MRI: magnetic resonance image.