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1Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, India
2Department of Surgery, Mata Gujri Memorial Medical College and Lions Seva Kendra Hospital, Kishanganj, India
3Department of Surgery, Banas Medical College and Research Institute, Palanpur, Palanpur, India
4Department of Clinical Research, Garg Fistula Research Institute, Panchkula, India
© 2024 The Korean Society of Coloproctology
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Funding
None.
Acknowledgments
The authors would like to thank Sattyadeep Garg (Department of Electronic Engineering, Indian Institute of Technology, Kanpur, India) for his assistance with the diagrams and software.
Author contributions
Conceptualization: PG, VDY, GM; Data curation: PG, KB; Formal analysis: PG, KB, GM; Methodology: PG, KB, GM; Project administration: PG, GM; Resources: PG, VDY; Software: PG, VDY, KB; Supervision: PG, GM; Validation: PG, KB, GM; Visualization: PG, VDY, GM; Writing–original draft: PG, KB; Writing–review & editing: all authors. All authors read and approved the final manuscript.
“Low” fistula involves no more than 1/3 of the external sphincter, while “high” involves more than 1/3 of the sphincter.
RIFIL, roof of ischiorectal fossa inside levator ani muscle.
aSimple, fistulotomy can be performed safely; complex, fistulotomy can be avoided and a sphincter-saving procedure performed. bAssociated comorbidities include already damaged/weakened sphincter, history of radiotherapy, and Crohn disease.
Parameter | Scoring | Weight | Possible weighted score | |
---|---|---|---|---|
Minimum | Maximum | |||
MRI assessment 3 mo after surgery | ||||
1. Nonhealing of internal (primary) opening | Healed, 0 | 4 | 0 | 4 |
Not healed, 1 | ||||
2. Nonhealing of fistula tract in the intersphincteric space | Healed, 0 | 4 | 0 | 4 |
Not healed, 1 | ||||
3. Nonhealing of external tracts in the ischiorectal fossa | Healed, 0 | 1 | 0 | 1 |
Not healed, 1 | ||||
4. Development of a new abscess in the intersphincteric space during the postoperative period | No, 0 | 4 | 0 | 4 |
Yes, 1 | ||||
Clinical assessment 3 mo after surgery | 0 | |||
5. Flatus passage from any of the external openings (even occasionally) | No, 0 | 4 | 0 | 4 |
Yes, 1 | ||||
6. Discharge from any external opening or anus | No, 0 | 1 | 0 | 3 |
Serous, 1 | ||||
Purulent (lower amount, <50% of preoperative quantity), 2 | ||||
Purulent (higher amount, >50% of preoperative quantity), 3 | ||||
Total | - | - | 0 | 20 |
Grade | Park sclassification | St. James University Hospital classification | Garg classification |
---|---|---|---|
I | Intersphincteric | Intersphincteric linear | Low transsphincteric/low or high intersphincteric: single tract |
II | Transsphincteric | Intersphincteric with extension(s) or associated abscess | Low transsphincteric/low or high intersphincteric: multiple tracts horseshoe or associated abscess |
III | Suprasphincteric | Transsphincteric linear | IIIA: high transsphincteric (single tract) |
IIIB: anterior fistula in a female patient or any lower grade fistula with associated comorbiditiesa | |||
IV | Extrasphincteric | Transsphincteric with extension(s) or associated abscess | High transsphincteric: multiple tract horseshoe or associated abscess |
V | - | Supralevator and translevator extension | Suprasphincteric or supralevator orextrasphincteric or RIFIL fistula |
Grade | Fistula description | Severitya |
---|---|---|
I | Low (single tract; intersphincteric or transsphincteric) | Simple |
II | Low (multiple tracts or associated abscess or horseshoe tract; intersphincteric or transsphincteric) | Simple |
III | High (single tract; intersphincteric or transsphincteric), anterior fistula in a female patient, or associated comorbiditiesb | Complex |
IV | High (multiple tracts or associated abscess or horseshoe tract; intersphincteric or transsphincteric) | Complex |
V | Suprasphincteric, supralevator, extrasphincteric, or RIFIL | Complex |
Incontinence type | Weight | Frequency (point) | Maximum score | ||
---|---|---|---|---|---|
Never | Occasional (≤1 episode/week) | Common (>1 episode/wk) | |||
Solid | 8 | 0 | 1 | 2 | 16 |
Liquid | 8 | 0 | 1 | 2 | 16 |
Urge | 7 | 0 | 1 | 2 | 14 |
Flatus | 6 | 0 | 1 | 2 | 12 |
Mucus | 6 | 0 | 1 | 2 | 12 |
Stress | 5 | 0 | 1 | 2 | 10 |
Total | - | - | - | - | 80 |
Variable | Wexner score | Vaizey score | FISI | GIS |
---|---|---|---|---|
Comprehensive | No | No | No | Yes |
FI type included | ||||
Urge FI | No | Yes | No | Yes |
Mucous FI | No | No | Yes | Yes |
Presence of confounding parameters like “need to wear a pad,” “need to take constipation-causing medicine,” and “alteration of lifestyle” | Yes | Yes | No | No |
Assignment of weights to each FI by an objective method | No | No | No | Yes |
Inclusion of patient perceptions (n) | 0 | 0 | 34 | 50 |
Inclusion of laypersons’ perceptions (n) | 0 | 0 | 0 | 50 |
Simple and easy to use | +++++ | +++++ | + | +++++ |
Detailed structured definitions | No | No | No | Yes |
In-depth disability scores based on an objective description system | No | No | No | 4D3L |
A total weighted score <8 indicates healing; a total weighted score ≥8 indicates nonhealing. MRI, magnetic resonance imaging.
Low fistula involves no more than 1/3, while high fistula involves more than 1/3, of the sphincter. RIFIL, roof of ischiorectal fossa inside levator ani muscle. Comorbidities include Crohn disease, existing sphincter injury/weakness, and history of radiation.
“Low” fistula involves no more than 1/3 of the external sphincter, while “high” involves more than 1/3 of the sphincter. RIFIL, roof of ischiorectal fossa inside levator ani muscle. aSimple, fistulotomy can be performed safely; complex, fistulotomy can be avoided and a sphincter-saving procedure performed. bAssociated comorbidities include already damaged/weakened sphincter, history of radiotherapy, and Crohn disease.
Score in a cell = (weight for that incontinence type) × (frequency points). For example, a person with occasional liquid incontinence would have a score of 8×1=8. The maximum possible score is 80 (indicating total incontinence), while the minimum score is 0 (indicating no incontinence).
FI, fecal incontinence; FISI, Fecal Incontinence Severity Index; GIS, Garg Incontinence Scores; 4D3L, 4 dimensions and 3 levels (modifed EQ-5D [EuroQol] description system).