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

Table 1 Patient and fistula characteristics in 1250 patients

	Fistulotomy	TROPIS	PERFACT	Anal fistula plug
Number of patients (Total = 1250)	611	408	175	56
Total surgical procedures performed including repeat procedures in a few patients (Total = 1351)	618	456	216	61
Follow-up, median (Range)	40 mo (1-105)	30 mo (1-70)	78 mo (13-93)	151 mo (105-171)
M/F	510/101	372/36	146/29	52/4
Age	37.5 ± 10.7	40.5 ± 11.1	41.7 ± 12.1	49.0 ± 10.9
Fistula type	Simple	High complex	High complex	Simple + complex
SJUH classification	I-206, II-143, III-79, IV-179, V-4	I-1, II-33, III-15, IV-234, V-125	I-0, II-6, III-43, IV-105, V-21	Complex-39, Simple-17
GARG classification	I-270, II-327, III-10, IV-0, V-4	I-1, II-42, III-16, IV-224, V-125	I-0, II-6, III-44, IV-104, V-21
Parks	I-349, II-258, III-4, IV-0	I-34, II-249, III-125, IV-0	I-6, II-148, III-21, IV-0
Excluded	93 (Short FU-30 Lost to FU-63)	51 (Short FU-38 Lost to FU-13)	26 (Lost to FU)	25 (Lost to FU)
Healing after first surgery	97.3% (504/518)	78.2% (279/357)	35.6% (53/149)	19.4% (6/31)
Overall healing rate (Median follow-up)	98.6% (511/518)	86% (307/357)	50.3% (75/149)	19.4% (6/31)

PERFACT: Proximal superficial cauterization of the internal opening and emptying regularly of fistula tracts and curettage of tracts; SJUH: St James’s University Hospital; TROPIS: Transanal opening of intersphincteric space.

Table 2 Results achieved in patients managed by the Garg Fistula Research Institute algorithm and treated by transanal opening of intersphincteric space and fistulotomy

	Total (n = 1019)	Subgroup analysis
		Supralevator fistulas (n = 129)	Horseshoe fistula (n = 203)	Associated abscess (n = 258)	No abscess (n = 761)
Excluded	144 (Lost to FU-76, Short FU-68)	17 (Lost to FU-3, Short FU-14)	27 (Lost to FU-8, Short FU-19)	35 (Lost to FU-18, Short FU-17)	109 (Lost to FU-58, Short FU-51)
Healing after first surgery	89.5% (783/875)	73.2% (82/112)	76.7% (135/176)	85.2% (190/223)	90.9% (593/652)
Overall healing rate	93.5% (818/875)	82.1% (92/112)	85.8% (151/176)	90.6% (202/223)	94.5% (616/652)
				P = 0.0578 (not significant)

Age: 38.7 ± 11.1; Sex: 882 male/137 female; Follow-up: 33 mo (range 1-105); Procedures performed: 611 fistulotomies, 408 transanal opening of the intersphincteric space procedures.

Table 3 Transanal opening of the intersphincteric space procedure: Preoperative and postoperative incontinence scores at the long-term follow-up

	Preoperative (n = 357)	Postoperative (n = 357)	Significance
Incontinence (number of patients)	Nil = 334, Gas = 16, Liquid = 6, Solid = 1, Urge = 0	Nil = 328, Gas = 20, Liquid = 6, Solid = 1, Urge = 2	P = 0.47, Not significant, (Fisher exact test)
Vaizey continence scores (mean)	0.077 ± 0.33	0.112 ± 0.44	P = 0.10, Not significant, (Wilcoxon signed rank test)

Vaizey incontinence scores range from minimum = 0 (perfect continence) to 24 (total incontinence). Scores are given for 7 parameters- incontinence to gas (0-4), liquid (0-4), solid (0-4), alteration in lifestyle (0-4), urge incontinence (0-4), need to wear a pad (0-2) or take constipating medicines (0-2).

Table 4 Fistulotomy procedure: Preoperative and postoperative Incontinence scores at long-term follow-up

	Preoperative (n = 518)	Postoperative (n = 518)	Significance
Incontinence (number of patients)	Nil = 512, Gas = 3, Liquid = 2, Solid = 1, Urge = 0	Nil = 504, Gas = 7, Liquid = 4, Solid = 1, Urge = 2	P = 0.11, Not significant, (Fisher Exact test)
Vaizey continence score (mean)	0.037 ± 0.47	0.050 ± 0.34	P = 0.068, Not significant, (Wilcoxon signed rank test)

Table 5 Comparison of the short- and long-term success rates of procedures performed

	Fistulotomy		TROPIS		PERFACT		Anal fistula plug
	Short-term (2018)[22]	Long-term follow-up	Short-term (2017)[19]	Long-term follow-up	Short-term (2015)[18]	Long-term follow-up	Short-term (2009)[21]	Long-term follow-up
n	353	611	52	408	44	175	23	56
Follow-up-median (Range)	27 mo (4-66)	40 mo (1-105)	9 mo (6-21)	30 mo (1-70)	9 mo (5-14)	78 mo (42-88)	10 mo (6-18)	151 mo (105-171)
Overall healing rate	100%	98.6%	90.4%	86%	86.4%	50.3%	71.4%	19.4%

PERFACT: Proximal superficial cauterization of the internal opening and emptying regularly of fistula tracts and curettage of tracts; TROPIS: Transanal opening of intersphincteric space.

Table 6 Anal fistula classification

Classification	Parks	St James University Hospital	GARG
Grade I	Intersphincteric	Intersphincteric- linear	Low fistula- single tract (intersphincteric or transsphincteric)
Grade II	Transsphincteric	Intersphincteric-multiple tracts or associated abscess	Low fistula- multiple tracts or associated abscess or horseshoe tract (intersphincteric or transsphincteric)
Grade III	Suprasphincteric	Transsphincteric- linear	High fistula-single tract (intersphincteric or transsphincteric) or anterior fistula in a female or associated comorbidities1
Grade IV	Extrasphincteric	Transsphincteric-multiple tract or associated abscess	High fistula- multiple tracts or associated abscess or horseshoe tract (transsphincteric)
Grade V	NA	Supralevator or translevator/extrasphincteric	Suprasphincteric or supralevator or extrasphincteric

¹Crohn’s disease, sphincter injury or post radiation exposure. Low fistula- involves < 1/3 of the external sphincter; high fistula-involves > 1/3 of the external sphincter. NA: Not applicable.