Annals of Coloproctology

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Technical Note

Transanal opening of the intersphincteric space (TROPIS): a novel procedure on the horizon to effectively manage high complex anal fistulas: Pankaj Garg, Anvesha Mongia; Ann Coloproctol. 2024;40(1):74-81. Published online October 24, 2023; DOI: https://doi.org/10.3393/ac.2022.01263.0180

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Anal fistulas, especially complex and high fistulas, are difficult to manage. The transanal opening of the intersphincteric space (TROPIS) procedure was first described in 2017, and a high success rate of over 90% was reported in high complex fistulas. Since then, more studies and even a meta-analysis have corroborated the high efficacy of this procedure in high fistulas. Conventionally, the main focus was to close the internal (primary) opening for the fistula to heal. However, most complex fistulas have a component of the fistula tract in the intersphincteric plane. This component is like an abscess (sepsis) in a closed space (2 muscle layers). It is a well-known fact that in the presence of sepsis, healing by secondary intention leads to better results than attempting to heal by primary intention. Therefore, TROPIS is the first procedure in which, instead of closing the internal opening, the opening is widened by laying open the fistula tract in the intersphincteric plane so that healing can occur by secondary intention. Although the drainage of high intersphincteric abscesses through the transanal route was described 5 decades ago, the routine utilization of TROPIS for the definitive management of high complex fistulas was first described in 2017. The external anal sphincter (EAS) is completely spared in TROPIS, as the fistula tract on either side of the EAS is managed separately—inner (medial) to the EAS by laying open the intersphincteric space and outer (lateral) to the EAS by curettage or excision.

Citations

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Steps to Enhance the Cure Rate of the TROPIS Procedure in Complex Anal Fistulas
Pankaj Garg, Vipul Yagnik, Kaushik Bhattacharya
ANZ Journal of Surgery.2026; 96(3): 693. CrossRef
Clinical efficacy and failure-related factors of the loose-seton procedure combined with transanal opening of the intersphincteric space technique (LoSet-TROPlS) in the treatment of complex anal fistulas
Qinghan Ma, Mengqing Dong, Hongwei Hua, Zhenyi Wang, Jiong Wu, Lei Jin
Techniques in Coloproctology.2026;[Epub] CrossRef
Cutting of Intersphincteric Space Procedure in Anal Fistulas Is Fundamentally Similar to Transanal Opening of the Intersphincteric Space Procedure
Pankaj Garg, Kaushik Bhattacharya, Vipul D Yagnik, Garg Mahak
Journal of the American College of Surgeons.2026; 242(5): 1461. CrossRef
Perianal fistula a silent epidemic that face proctology and coloproctology in public health
Alida Vallejo-López , Josefina Ramírez-Amaya , Cesar Noboa-Terán
Salud, Ciencia y Tecnología.2025; 5: 1360. CrossRef
TROPIS is effective in managing complex anal fistulas with additional supralevator rectal opening (ASRO) by Garg phenomenon
Nicola Clemente, James C.W. Khaw, Yuliya Medkova, Pankaj Garg
Cirugía Española (English Edition).2025; 103(6): 800101. CrossRef
Response to the Letter to the Editor regarding our article on efficacy one year after the TROPIS Technique for the treatment of complex anal fistula
Fernando de la Portilla de Juan, María Luisa Reyes Díaz, Fátima Hinojosa Ramirez
Cirugía Española (English Edition).2025; 103(6): 800119. CrossRef
Respuesta a la carta al editor sobre nuestro artículo «Eficacia al año de la técnica TROPIS en la fístula perianal compleja»
Fernando de la Portilla de Juan, María Luisa Reyes Díaz, Fátima Hinojosa Ramirez
Cirugía Española.2025; 103(6): 800119. CrossRef
Systematic review and meta-analysis of Transanal Opening of Intersphincteric Space (TROPIS) versus conventional treatments for anal fistula
Yang-Tao Chen, Zhao-Chu Wang, Ya-Meng Xie, Xun Wang, Xu-Xiong Wu, Yang Li, Rong Shi, Jing Wang
Surgery Open Science.2025; 27: 15. CrossRef
TROPIS is effective in managing complex anal fistulas with additional supralevator rectal opening (ASRO) by Garg phenomenon
Nicola Clemente, James C.W. Khaw, Yuliya Medkova, Pankaj Garg
Cirugía Española.2025; 103(6): 800101. CrossRef
Transanal opening of intersphincteric space (TROPIS) treatment for high complex anal fistula: a systematic review and meta-analysis
Pengfei Zhou, Jingen Lu, Yanting Sun, Jiawen Wang
International Journal of Surgery.2025; 111(10): 7301. CrossRef
The Management of the Intersphincteric Component of Anal Fistula Tract Is Pivotal in Response to “A Pilot Study of Porcine Acellular Bladder Matrix Filling in the Treatment of Anal Fistulas”
Pankaj Garg, Vipul Yagnik, Kaushik Bhattacharya
ANZ Journal of Surgery.2025; 95(12): 2626. CrossRef
Recent advances in the diagnosis and treatment of complex anal fistula
Pankaj Garg, Kaushik Bhattacharya, Vipul D. Yagnik, G. Mahak
Annals of Coloproctology.2024; 40(4): 321. CrossRef
Tissue engineering and regenerative medicine approaches in colorectal surgery
Bigyan B. Mainali, James J. Yoo, Mitchell R. Ladd
Annals of Coloproctology.2024; 40(4): 336. CrossRef
Achieving a high cure rate in complex anal fistulas: understanding the conceptual role of the Garg cardinal principles
Pankaj Garg, Nicola Clemente, James C. W. Khaw
Annals of Coloproctology.2024; 40(5): 521. CrossRef
Comparative Evaluation Between Cutting of the Intersphincteric Space vs Cutting Seton in High Anal Fistula: A Randomized Controlled Trial
Jiawei Qin, Yanlan Wu, Xueping Zheng, Kunlan Wu, Gongjian Dai, Yanyan Tan, Xu Yang, Yuqing Sun
Journal of the American College of Surgeons.2024; 239(6): 563. CrossRef
Invited Commentary: The Quest for the Panacea Treatment for Anal Fistula
Steven D Wexner
Journal of the American College of Surgeons.2024; 239(6): 573. CrossRef

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