Non-Locatable Internal Opening in Anal Fistula Associated with Acute Abscess and Its Definitive Management by Garg Protocol

Abstract

Background: Definitive management of acute fistula-abscess (anal fistulas associated with acute abscess) is gaining popularity against the two-staged approach (early abscess drainage with deferred fistula management). However, locating an internal opening (IO) in acute fistula-abscess can be difficult. A recent protocol (Garg protocol) has been shown to be effective in managing anal fistulas with non-locatable IO. Purpose: To test the efficacy of the Garg protocol in managing acute fistula-abscess with non-locatable IO. Methods: Patients with acute fistula-abscess operated by a definitive procedure were included. A preoperative MRI was done in all patients. Patients in whom the IO was non-locatable after clinical, MRI, and intraoperative examination were managed by the threestep Garg protocol. Garg protocol: 1) Reassessment of MRI; 2) In non-horseshoe fistulas, the IO was assumed to be at the point where the fistula tract reached closest to the sphincter-complex; 3) In horseshoe fistulas, the IO was assumed to be located in the midline (anterior or posterior as per the horseshoe location). Low fistulas were treated by fistulotomy and high fistulas by a sphincter-sparing procedure. The long-term healing rate and change in continence (Vaizey scores) were evaluated. Results: A total of 201 patients with acute fistula-abscess were operated over six years, and 19 were lost to follow-up. A total of 182 patients (154-males) were followed up (median-37 months). The IO was locatable in 133/182 (73.1%) (control group) and was nonlocatable in 49/182 (26.9%) (study group). The study group was managed as per the Garg protocol. The age, sex-ratio, and fistula parameters were comparable in both groups. The long-term healing rate was 112/133(84.2%) in the IO-locatable group and 43/49 (87.8%) in the IO-non-locatable group (p=0.64, not-significant). The objective continence scores did not change significantly after surgery in both groups. Conclusion: Acute fistula-abscess with non-locatable IO can be managed successfully by the Garg protocol without any risk of incontinence.

Efficacy and safety of transanal opening of intersphincteric space in the treatment of high complex anal fistula: A meta‑analysis

“…Garg et al (40) found that TROPIS surgery in 546 patients (IO found) and 154 patients (IO not found) had roughly the same cure rate (89 vs. 90.9%) and there was no significant difference in postoperative anal incontinence scores between the two groups. This was subsequently confirmed by Yagnik et al (41) who showed that even if the IO cannot be determined, the cure rate of TROPIS can reach 87.8%. For HCAF, it is necessary to open the sphincter space, maintain continuous drainage and remove the sinus tract as completely as possible while reducing sphincter injury.…”

“…When infection is present in the sphincter space, the infection can easily induce local tissue degeneration and necrosis and severe inflammatory response, and the epidermis can regenerate only when the infection is controlled and the necrotic tissue is cleared, which may be the reason for the high healing rate of TROPIS in complex fistulas ( 11 ). A recent study showed that the cure rate of TROPIS in acute fistula-abscess was 85.2% (155/182) ( 41 ).…”

The use of a loose seton as a definitive surgical treatment for anorectal abscesses and complex anal fistulas

“…If the horseshoe fistula is located posteriorly, the internal opening is assumed to be on the posterior midline, while in anterior horseshoe fistulas, it is assumed to be on the anterior midline, and it is recommended to manage fistulas accordingly. 25 Thus, the Garg protocol effectively helps to find the internal os of fistulas.…”

The management of complex fistula in ano by transanal opening of the intersphincteric space (TROPIS): short-term results

“…However, TROPIS had the highest success rate. Furthermore, when an internal opening is not identified in complex fistulas, the TROPIS procedure applying the Garg protocol has helped to treat anal fistulas successfully [19,20]. Moreover, there was very little risk of the postoperative deterioration of anal continence Other advantages of TROPIS include the fact that it requires no special instruments, is easy to learn and to teach, and can be performed cost-effectively in small surgical setups in low-and middle-income countries, unlike other newer treatment modalities for complex fistula in ano.…”