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Anorectal benign disease

Recent advances in the diagnosis and treatment of complex anal fistula: Pankaj Garg, Kaushik Bhattacharya, Vipul D. Yagnik, G. Mahak; Ann Coloproctol. 2024;40(4):321-335. Published online August 30, 2024; DOI: https://doi.org/10.3393/ac.2024.00325.0046

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Anal fistula can be a challenging condition to manage, with complex fistulas presenting even greater difficulties. The primary concerns in treating this condition are a risk of damage to the anal sphincters, which can compromise fecal continence, and refractoriness to treatment, as evidenced by a high recurrence rate. Furthermore, the treatment of complex anal fistula involves several additional challenges. Satisfactory solutions to many of these obstacles remain elusive, and no consensus has been established regarding the available treatment options. In summary, complex anal fistula has no established gold-standard treatment, and the quest for effective therapies continues. This review discusses and highlights groundbreaking advances in the management of complex anal fistula over the past decade.

Citations

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Long-term outcomes of video-assisted anal fistula treatment
Sirindhra Suepiantham, Giovanni Santoro, Michael Chadwick, Ramya Kalaiselvan, Ajai Samad, Rajasundaram Rajaganeshan
Surgical Endoscopy.2026;[Epub] CrossRef
Understanding the anatomical basis of anorectal fistulas and their surgical management: exploring different types for enhanced precision and safety
Asim M. Almughamsi, Yasir Hassan Elhassan
Surgery Today.2025; 55(4): 457. CrossRef
Mucosal advancement flap versus ligation of the inter-sphincteric fistula tract for management of trans-sphincteric perianal fistulas in the elderly: a retrospective study
Tamer A. A. M. Habeeb, Massimo Chiaretti, Igor A. Kryvoruchko, Antonio Pesce, Aristotelis Kechagias, Abd Al-Kareem Elias, Abdelmonem A. M. Adam, Mohamed A. Gadallah, Saad Mohamed Ali Ahmed, Ahmed Khyrallh, Mohammed H. Alsayed, Esmail Tharwat Kamel Awad, M
International Journal of Colorectal Disease.2025;[Epub] CrossRef
Evaluating the predictive superiority of Garg's classification for surgical decision-making in perianal fistula management
Naresh Lodhi, Dileep Thakur, Amrendra Verma, Uday Somashekar, Deepti Bala Sharma, Dhananjaya Sharma
Tropical Doctor.2025; 55(2): 124. CrossRef
Tuberculosis in anal fistula: incidence, clinical insights, and diagnostic challenges
Tariq Akhtar Khan, Mohammad Ali, Krishna Pada Saha, M. Nashir Uddin, M. Lutful Kabir Khan, Nunjirul Muhsenin, Nazmun Nahar, Sawantee Joarder, M. Kuddus Ali Khan
International Surgery Journal.2025; 12(5): 717. CrossRef
Validation of a novel imaging-guided and anatomy-based classification system for anorectal fistulas: a retrospective clinical evaluation study
Antonio Brillantino, Francesca Iacobellis, Luigi Marano, Adolfo Renzi, Pasquale Talento, Luigi Brusciano, Claudio Gambardella, Umberto Favetta, Michele Schiano Di Visconte, Luigi Monaco, Maurizio Grillo, Mauro Natale Maglio, Fabrizio Foroni, Alessio Palum
Annals of Coloproctology.2025; 41(3): 207. CrossRef
Application of micro-dynamic negative pressure wound therapy in treating cavity wounds after complex anal fistula surgery
Ruyun Cai, Zhonghua Hong
Asian Journal of Surgery.2025; 48(12): 7854. CrossRef
Hotspots and trends of perianal fistula of Crohn’s disease: A bibliometric analysis
Lei Liang, Lan Li, Dexin Wang, Xiubi Zhang, Xiaohe Zhang, Gang Tian, Chaochi Yue, Weiliang Du
Medicine.2025; 104(32): e43854. CrossRef
IL-6 and TNF variants as potential determinants of perianal disease in Crohn's patients: a pilot study
Jessica Cusato, Gian Paolo Caviglia, Alfredo Santovito, Gabriele Ascani, Alessandra Manca, Marta Vernero, Angelo Armandi, Eleonora Dileo, Miriam Antonucci, Maria Alessandra Pavan, Antonio D'Avolio, Davide Giuseppe Ribaldone
Cytokine.2025; 196: 157064. CrossRef
Mucosal Advancement Flap Versus Ligation of the Intersphincteric Fistula Tract for Transsphincteric Fistula-in-Ano: A Comparative Study in a Tertiary Care Hospital
Sagar Reddy G, Ashok Reddy R
Cureus.2025;[Epub] CrossRef
Ayurveda management of Bhagandara (~Fistula-in-ano) with coexisting Arsha (~Hemorrhoids)
Nasreen Hanifa, Hemantha Kumar Parlapothula, Rekha Chandrodaya
Journal of Ayurveda Case Reports.2025; 8(4): 247. CrossRef
Levator ani involvement in perianal fistulas: MRI-based insights into complex anatomy
Sezer Nil Yılmazer Zorlu, Diğdem Kuru Öz, Ayşe Erden
Abdominal Radiology.2025;[Epub] CrossRef
From the Editor: Uniting expertise, a new era of global collaboration in coloproctology
In Ja Park
Annals of Coloproctology.2024; 40(4): 285. CrossRef
Surgeon oriented reporting template for magnetic resonance imaging and endoanal ultrasound of anal fistulas enhances surgical decision-making
Si-Ze Wu
World Journal of Radiology.2024; 16(12): 712. CrossRef
Abbreviations Anonymous: A Coloproctologist’s Guide to Sanity
Kaushik Bhattacharya
Indian Journal of Colo-Rectal Surgery.2024; 7(1): 1. CrossRef

Case Report

Anorectal benign disease

Chronic fistula in ano associated with adenocarcinoma: a case report with a review of the literature: Nalini Kanta Ghosh, Ashok Kumar; Ann Coloproctol. 2024;40(Suppl 1):S1-S5. Published online May 16, 2024; DOI: https://doi.org/10.3393/ac.2022.00752.0107

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Abstract PDF

The malignant transformation of chronic fistula in ano is rare, accounting for 3% to 11% of all anal canal malignancies. It results from long-standing inflammation and chronic irritation. No guidelines are available for the management of these cases. We herein present a case report of a 55-year-old man who presented with a history of constipation, perianal pain, and discharging fistula in ano of 4-year duration and underwent fistula surgery with recurrence. Biopsy of the fistulous tract revealed adenocarcinoma. He received neoadjuvant chemoradiotherapy, followed by abdominoperineal excision including excision of the fistulous tract. After 18 months of follow-up, he is free of recurrence. We present this case with a review of the literature, highlighting the management strategies.

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A Long-standing Perianal Fistula Hiding an Adenocarcinoma: A Case Report
I-Wei Lin, Ying-Wen Su, Ching-Heng Ting, Ming-Jen Chen
Journal of Cancer Research and Practice.2026;[Epub] CrossRef

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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333 Download
11 Web of Science
14 Citations

Abstract PDF

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

Citations to this article as recorded by

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;[Epub] 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

Original Articles

The Ligation of Intersphincteric Fistula Tract Technique: A Preliminary Experience: Pasquale Cianci, Nicola Tartaglia, Alberto Fersini, Libero Luca Giambavicchio, Vincenzo Neri, Antonio Ambrosi; Ann Coloproctol. 2019;35(5):238-241. Published online October 31, 2019; DOI: https://doi.org/10.3393/ac.2018.08.16.1

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11 Citations

Abstract PDF

Purpose
Surgery is the only treatment for anal fistula. Many surgical techniques have been described. The aim of this study was to communicate the authors’ preliminary experience in the use of a recently proposed, simplified technique.
Methods
This was a prospective study of 28 patients admitted from January 13, 2016 through July 20, 2017. Patients were managed with the ligation of intersphincteric fistula tract (LIFT) technique and results were observed and documented, including recurrence rate, incontinence rate, and other postoperative complications.
Results
A total of 28 patients were studied. The mean operation time was 31 minutes (range, 23–44 minutes), and there were no intra- and postoperative complications. The overall complete healing rate was 85.7%, and the recurrence rate was 14.2%. Follow-up was conducted at 1, 3, and 6 months.
Conclusion
Many surgical techniques have been described for the treatment of anal fistula. The correct choice of surgical technique out of available procedures is the most important factor for proper treatment and reducing the risk of recurrence or incontinence. In the authors’ experience, the LIFT technique is simple and easy to learn, and is a good choice for the treatment of simple anal fistula; however, a tailored surgery remains the gold standard for this condition.

Citations

Citations to this article as recorded by

Ligation of intersphincteric fistula tract for complex fistula in ano at a tertiary care centre in Northern India: A 3-year prospective study
Musharraf Husain, Mir Mujtaba Ahmad, Tajamul Rashid, Ajay Kumar Thakral
Journal of Clinical Sciences.2025; 22(1): 27. CrossRef
Is the ligation of the intersphincteric fistula tract (LIFT) procedure truly a sphincter preserving procedure for anal fistula? A scoping review of the literature
Ian Jse-Wei Tan, Bei En Siew, Jerrald Lau, Carol Pei Ling Yap, Stephanie Marie May Ee Soon, Ker-Kan Tan
European Journal of Medical Research.2025;[Epub] 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
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
Evaluation of the outcomes of fistulotomy with primary sphincter reconstruction in the management of high trans-sphincteric fistula and supra-sphincteric fistula-in-ano
Basma Hussein Abdelaziz Hassan, Philobater Bahgat Adly Awad, Mostafa Mohamed Abdelaziz, Mohammed Hossam, Mohamed Ali Mohamed Nada
Die Chirurgie.2024; 95(S1): 6. CrossRef
Avoiding Recurrence of Anorectal Abscess: The Impact of Patient Delay in Seeking Medical Attention
Sonu Nimesh Patel, Ria Elizabeth Philip, Dillon Downs, Arthur Alan Topilow, Ramisa Anjum, Glenn Scot Parker
Journal of Coloproctology.2024; 44(04): e253. CrossRef
Ligation of Intersphincteric Fistula Tract (LIFT) for the Treatment of Anal Fistula: A Prospective Observational Study
L.A. Hidalgo-Grau, N. Ruiz-Edo, O. Estrada-Ferrer, E.M. García-Torralbo, M. del Bas-Rubia, P. Clos-Ferrero, E. Bombuy-Giménez
Journal of Coloproctology.2023; 43(01): 024. CrossRef
Surgical treatment of anal fistula
A. Ya. Ilkanich, V. V. Darwin, E. A. Krasnov, F. Sh. Aliyev, K. Z. Zubailov
Сибирский научный медицинский журнал.2023; 43(5): 74. CrossRef
Advancing standard techniques for treatment of perianal fistula; when tissue engineering meets seton
Hojjatollah Nazari, Zahra Ebrahim Soltani, Reza Akbari Asbagh, Amirsina Sharifi, Abolfazl Badripour, Asieh Heirani Tabasi, Majid Ebrahimi Warkiani, Mohammad Reza Keramati, Behnam Behboodi, Mohammad Sadegh Fazeli, Amir Keshvari, Mojgan Rahimi, Seyed Mohsen
Health Sciences Review.2022; 3: 100026. CrossRef
Efficacy and safety of ligation of intersphincteric fistula tract in the treatment of anal fistula
Jiaji Zhang, Xilu Hao, Yican Zhu, Ronggang Luan
Medicine.2021; 100(4): e23700. CrossRef
Efficacy and safety of an innovatively modified cutting seton technique for the treatment of high anal fistula
Jie Jiang, Yang Zhang, Xufeng Ding, Naijin Zhang, Lijiang Ji
Medicine.2021; 100(5): e24442. CrossRef

Diagnosis and Management of a Cryptoglandular Actinomycotic Fistula-in-Ano: An Update on 7 New Cases and a Review of the Literature: Axel Egal, Isabelle Etienney, Heym Beate, Jean Francois Fléjou, Charles André Cuenod, Patrick Atienza, Pierre Bauer; Ann Coloproctol. 2018;34(3):152-156. Published online June 30, 2018; DOI: https://doi.org/10.3393/ac.2017.07.23

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3 Citations

Abstract PDF

Purpose
Primary anal actinomycosis of cryptoglandular origin, a rare cause of anal suppurative disease, requires specific management to be cured. The aims of this retrospective study were to describe clinical, morphological, and microbiological features of this entity and to evaluate management practices for new cases observed since 2001.
Methods
This was a retrospective case series conducted at the Diaconesses-Croix Saint-Simon Hospital in Paris.
Results
From January 2001 to July 2016, 7 patients, 6 males and 1 female (median, 49 years), presenting with an actinomycotic abscess with a cryptoglandular anal fistula were included for study. The main symptom was an acute painful ischioanal abscess. One patient exhibited macroscopic small yellow granules (“sulfur granules”), another “watery pus” and a third subcutaneous gluteal septic metastasis. All patients were overweight (body mass index ≥ 25 kg/m²). Histological study of surgically excised tissue established the diagnosis. All the patients were managed with a combination of classical surgical treatment and prolonged antibiotic therapy. No recurrence was observed during follow-up, the median follow-up being 3 years.
Conclusion
Actinomycosis should be suspected particularly when sulfur granules are present in the pus, patients have undergone multiple surgeries or suppuration has an unusual aspect. Careful histological examination and appropriate cultures of pus are needed to achieve complete eradication of this rare, but easily curable, disease.

Citations

Citations to this article as recorded by

Skin and Soft Tissue Actinomycosis in Children and Adolescents
Salih Demirhan, Erika Orner, Wendy Szymczak, Philip J. Lee, Margaret Aldrich
Pediatric Infectious Disease Journal.2024; 43(8): 743. CrossRef
Development of a new patient-reported outcome measure for complex cryptoglandular fistulas (20-Item complex cryptoglandular fistula questionnaire™): a qualitative study
Jeffrey D. McCurdy, Patrick Crooks, Chad Gwaltney, Robert Krupnick, Kathy-Ann Cadogan, Chitra Karki
Journal of Patient-Reported Outcomes.2024;[Epub] CrossRef
Perianal Actinomycosis: A Surgeon’s Perspective and Review of Literature
Alexios Dosis, Atia Khan, Henrietta Leslie, Sahar Musaad, Adrian Smith
Annals of Coloproctology.2021; 37(5): 269. CrossRef

Retrospective Analysis of a Fistula-in-ano: Focus on an Anal-sphincter-preserving Procedure.: Han, Ki Su , Cho, Hyeon Min , Kim, Do Hyoung , Kim, Jun Gi; J Korean Soc Coloproctol. 2007;23(6):403-409.; DOI: https://doi.org/10.3393/jksc.2007.23.6.403

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27 Download
1 Citations

Abstract PDF

PURPOSE
The results of anal fistula treatments have improved with the development of the anal fistula operative technique. However, there are still complications, such as recurrence and anal incontinence. To this end, the authors classified anal fistulas by using Sumikoshi's classification and performed an anal-sphincter-preserving procedure.
METHODS
We experienced 98 anal fistula cases involving 86 patients who underwent anal fistula operations at The Catholic University of Korea, St. Vincent's Hospital from January 2001 to December 2006. This study was done retrospectively by chart review and telephone questioning. The follow-up period was from 2 to 72 months (mean 29.5, SD: 19.1).
RESULTS
The study showed 0 cases of Type I (0.0%), 49 cases of Type II (50.0%), 46 cases of Type III (46.9%), and 3 cases of Type IV (3.1%) fistulas. Among the 98 fistula-in-ano operations were 27 (27.6%) of fistulotomies and 71 (72.4%) sphincter-preserving procedures (2 cases of coring-out+muscle filling+rectal mucosal advancement flap, 31 cases of coring-out+ muscle closure+rectal mucosal advancement flap, 28 cases of coring-out+cutting seton, and 10 cases of loose seton). After the sphincter-preserving operation, there were 4 cases (4/71, 5.6%) of recurrence. There were no major disorders of the anal sphincter. However, minor disorders of the anal sphincter (6/71, 8.5%, soiling) were found.
CONCLUSIONS
The anal-sphincter-preserving procedure is very effective in preventing recurrence and anal incontinence, but these results are from a retrospective study with a small number of patients and the follow-up period was short. If further cases are collected and continuous follow-up is done, better results can be expected.

Citations

Citations to this article as recorded by

New Techniques for Treating an Anal Fistula
Kee Ho Song
Journal of the Korean Society of Coloproctology.2012; 28(1): 7. CrossRef

The Clinical Features and Charateristics of anal Cancer Arising from Chronic Fistula-in-ano.: Son, Byung Ho , Han, Won Kon , Kim, Heung Dae , Kim, Kwang Yun; J Korean Soc Coloproctol. 2002;18(6):373-378.

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Abstract PDF: PURPOSE
The incidence of unhealed chronic fistula is about 7% and the cancer can occur in the longstanding unhealed fistula. The most of the cancer is mucinous adenocarcinoma. The report is diverse about treatment, adjuvant chemotherapy and prognosis. The purpose of this study is review of the clinical characteristics and survival of the anal cancer arising from chronic fistula-in-ano.
METHODS
The number of patients was 10. The diagnosis is made under pathological examination at the Kanbuk Samsung Hospital from 1983 to 2000. The retrograde study was done with patients' records and telephone questionnaire. The survival rate was calculated with Kaplan-Meier method.
RESULTS
All patients were male. The patients had symptoms of anal discharge and anal swelling suggesting the anal fistula. The patients had history of anal surgery. The external openings were multiple. Seven patients had mucinous adenocarcinoma. The prognosis was poor. Among 8 patients' follow-up data, except one patient, 7 patients died within 43 months.
CONCLUSIONS
The anal cancer can occur in longstanding unhealed fistula. In our series, all patients were male, and they had multiple opening fistula. The patient who had small size tumor have only survived. Through meticulous exploring and deep biopsy of the fistula, early detection is best method to treat the anal cancer arising from chronic fistula-in-ano.

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