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84 P. Garg
Fig. 9 Grade IV fistula – a high transsphincteric fistula with a horseshoe abscess and multiple
branches in a 35-year-old male
6.5 Grade V: Suprasphincteric or Supralevator
or Extrasphincteric
See Figs. 10, 11, and 12.
6.6 Strong Points
1. It is the first classification to grade fistulas on the basis of “extent of the
involvement of the external sphincter” as low or high fistula rather than as
intersphincteric or transsphincteric fistula (Garg 2017a, 2018a, 2020).
2. This is the first classification which guided the surgeons through the management,
for those fistulas which can be safely managed by fistulotomy and those ones in
which fistulotomy should be strictly avoided. For example, a low transsphincteric
6 Classification of Anal Fistula and Abscess 85
Fig. 10 Grade V fistulas – schematic diagram
Fig. 11 Grade V fistula – a supralevator fistula in a 51-year-old male
86 P. Garg
Fig. 12 Grade V fistula – a suprasphincteric fistula in a 50-year-old male
fistula with multiple branches (Fig. 5) or an associated abscess (Fig. 4) can be
managed by fistulotomy because it is a simple fistula (grade II) according to the
Garg classification, but such a fistula would be classified as complex by the SJUH
(grade IV) or the Parks (grade II) classifications (Garg 2017, 2018).
3. Garg classification grades fistula according to the severity of the fistulas
(Garg 2018).
4. This classification is the most comprehensive classification to be proposed till
date. Unlike previous classifications, there is clarity about suprasphincteric,
supralevator, and extrasphincteric fistulas, and they have been clubbed together
as grade V fistulas (Garg 2018a, 2020). Also the anterior fistulas in females and
patients with comorbidities were classified in grade III fistulas (Garg 2017a,
2018a, 2020).
6 Classification of Anal Fistula and Abscess 87
5. Validated by a large MRI-based series of 440 operated fistula patients (Garg 2017a).
6. Recently a study analyzing 848 operated fistulas further corroborated the accuracy of this classification (Garg 2020).
6.7 Weak Points
1. The initial published classification was very detailed, hence a bit confusing to the
general surgeons (Garg 2017). Therefore, a simpler version of the same classification has been published and used extensively (Table 5) (Garg 2018a, b, c,
2019a, b, 2020; Garg et al. 2019).
7 Status of Extrasphincteric Fistulas
Extrasphincteric fistulas are considered to be the most complex of all fistulas and are
extremely difficult to treat (Fig. 10) (Gordon and Nivatvongs 2007). Parks et al. had
assigned these as a separate grade of most complex fistulas (grade IV). However,
Parks et al. did not categorize all translevator fistulas as extrasphincteric fistulas.
Only the translevator fistulas which were opening into the rectum high-up were
categorized as extrasphincteric fistulas (grade IVa) (Parks et al. 1976). The fistulas
which were crossing the levator muscles (translevator) and reached the pararectal
tissues but were not opening into the rectum were categorized along with transsphincteric fistula (grade IIb) (Parks et al. 1976). Similarly, the SJUH classification
had put extrasphincteric fistulas in grade V (Morris et al. 2000).
However, it seems that extrasphincteric fistulas do not exist or are extremely rare
(Garg 2016, 2017b, 2018c). Several studies including large series analyzing more
than 1300 MRI scans did not find even a single extrasphincteric fistula (Garg 2019b).
There could be three reasons for this finding:
1. It is possible that extrasphincteric fistulas were perhaps overdiagnosed as good
imaging modalities were not available in that era. During those times, high fistulain-ano were delineated and assessed only on operative findings and x-ray
fistulogram. Understandably, it must have been a difficult task to accurately
diagnose extrasphincteric fistulas based only on operat ive findings and/or
x-ray fistulogram. It is quite possible that many high transsphincteric or supralevator fistulas were inaccurately labeled as extrasphincteric fistula.
2. The second reason could be that extrasphincteric fistulas were mainly iatrogenous
(Parks et al. 1976). It is possible that this cause (iatrogenic) was much more
common five decades ago when there was no MRI or TRUS. Parks et al. reported
that extrasphincteric fistulas used to occur when a high translevator extension of
transsphincteric fistula (Parks grade IIb) was drained into the rectum (Ferguson
and Houston 1978; Parks et al. 1976). But wi th the advent of advanced
88 P. Garg
Fig. 13 A schematic diagram
explaining why an abscess
does not penetrate through the
levator muscle plate
radiological modalities (MRI & TRUS) and more understanding about the
anorectal anatomy and fistula pathophysiology over the last few decades, this
iatrogenically caused extrasphincteric fistulas have reduced drastically.
3. The third reason for rarity/nonexistence of extrasphincteric fistulas could be that
extrasphincteric fistulas are unlikely to occur from pathophysiological point of
view. Whenever there is a collection in ischiorectal fossa, it is extremely difficult
for the present pus to rupture into the supralevator space (Fig. 13) (Garg 2018).
This is because, first, there is a barrier in the form of the strong levator plate
(muscle). Secondly, when there is space available for an infection to spread into
the soft compressible tissue (fat) in ischiorectal fossa, it would require a large
amount of pus to generate enough pressure so that the abscess perforates the
muscle (Fig. 13) (Garg 2018c). Even if such a high pressure is generated, then by
that time the abscess invariably ruptures through the skin rather than rupturing
through the levator plate. Therefore, extrasphincteric fistulas rarely occur spontaneously (Ferguson and Houston 1978; Garg 2018c).
Due to these reasons, the extrasphincteric fistulas p erhaps do not exist, or are
much rarer than they are thought to be. Therefore, these fistulas should be diagnosed
only when there is strong evidence on MRI confirming their presence.
8 Evaluation of Existing Classifications on Long-Term Data
A recent study in a large number of patients (n ¼ 848) analyzed the validity of
existing classifications (Garg 2020). All patients were assessed by preoperative MRI
and were subsequently operated. The amount of external sphincter involvement was
assessed meticulously on MRI and on examination under anesthesia before
6 Classification of Anal Fistula and Abscess 89
proceeding with surgery. Fistulotomy was performed only in the fistulas in which it
was deemed absolutely safe to be done (low fistulas <1/3 external sphincter
involvement). In high fistulas (>1/3 external sphincter involvement), a sphinctersparing procedure was done (Garg 2021). These patients were meticulously
followed-up for up to 7 years (median follow-up to 3 years), and the continence
levels were evaluated by an objective scoring system (Vaizey’s continence scores)
(Garg 2020). There was no significant deterioration in the continence of either group
of patients (fistulotomy or sphincter-sparing procedure) (Garg 2020).
Retrospectively, all fistulas were classified through three classifications – Parks,
SJUH, and Garg. The lower grades of all classifications were classified as simple
(Parks: I, SJUH: I–II, Garg: I–II) whereas higher grades were classified as complex
(Parks: II–IV, SJUH: III–V, Garg: III–V) fistulas. Amenability of fistulas to
fistulotomy was analyzed by these classifications. Simple fistulas were assumed to
be amenable to fistulotomy, whereas fistulotomy would be contraindicated in complex fistulas and, if performed, it would lead to a high risk of incontinence.
Of all fistulas, 42.7% (n ¼ 215) fistulas classified as complex by the Parks and the
SJUH classifications were actually simple so that they could undergo fistulotomy
safely with no deterioration in continence levels (Table 6) (Garg 2020). This was a
major lacuna, as both these classifications tend to classify much more simple fistulas
Table 6 Amenability of fistulas to fistulotomy according to the existing classifications as analyzed
in a recent study (Garg 2020)
Were
Classification Grade
Parks Simple ¼ I (344) 344 308 (89.5%) 42.7% of fistulas
Complex ¼ II + III + IV
(412 + 92 + 0)
SJUH Simple ¼ I+II
(190 + 154)
Complex ¼ III + IV + V
(80 + 332 + 92)
Garg Simple ¼ I+II
(249 + 317)
Complex ¼ III + IV + V
(19 + 171 + 92)
SJUH – St James University Hospital classifi
Total
(n ¼ 848)
504 215 (42.7%)
344 308 (89.5%) 42.7% of fistulas
504 215 (42.7%)
566 520 (91.9%) Only 1% of fistulas
282 3 (1.0%)
cation
potentially
amenable to
fistulotomy Comment
classified as
“complex” were
amenable to
fistulotomy. This is
a major flaw
classified as
“complex” were
amenable to
fistulotomy. This is
a major flaw
classified as
“complex” were
amenable to
fistulotomy. These
three were anterior
fistula in females
and fistulotomy
could be done safely
90 P. Garg
in the complex category. The disadvantage is that these erroneously categorized
fistulas (42.7%) could have been conveniently and safely managed by fistulotomy
(which has success rate between 90 and 98% in the hands of most surgeons), but
with the Parks and the SJUH classifications, these fistulas would end up undergoing
a sphincter-saving procedure (success rate 30– 75%). This would unnecessarily
increase recurrence, morbidity, and suffering. On the other hand, of all patients
who could undergo fistulotomy, Garg classification correctly categorized 99% of
these fistulas as simple and only 1% as complex (Table 6).
Thus, the results of the study demonstrate that the Parks and SJUH classifications
tend to categorize a large subset of patients with simple fistulas in the complex
category. These patients are the ones which can safely undergo fistulotomy, but this
fact could have gone overseen due to the error in classification. This error is rectified
by Garg classificationas it is more accurate in separating simple from complex fistulas.
This study was pivotal because of several reasons:
1. This was perhaps the largest MRI-based series of operated anal fistula patients to
be published.
2. It had a long follow-up of 6–84 months (median 36 months).
3. The long-term continence levels were evaluated by objective continence scoring
(Vaizey’s scores).
4. This was the largest MRI-based study which compared and analyzed the validity
of existing classifications.
9 Conclusions
The classifi cation process has come a long way in the last nine decades. The two
most used classifications, the Parks and the St James’s Hospital University, have
been in usage since 1976 and 2000, respectively. The Parks classification was based
on clinical and operative findings, whereas the St James’s Hospital University
classification was MRI based. However, both these classificati ons suffered from
two major setbacks. First, they did not grade fistulas on their complexity, and second,
they did not provide any guidance in the management. These lacunae were addressed
in the recently proposed Garg classification. The latter graded fistulas based on their
complexity and provided management guidelines. Garg grades I–II can be safely
managed by fistulotomy, whereas fistulotomy is contraindicated in Garg grades III–
V. A sphincter-sparing procedure should be done in these fistulas. It would be
prudent if Garg classification is used by the radiologists in their reports, so that the
operating surgeons get maximum benefit from it.
6 Classification of Anal Fistula and Abscess 91
References
Eisenhammer S (1958) A new approach to the anorectal fistulous abscess based on the high
intermuscular lesion. Surg Gynecol Obstet 106(5):595–599
Ferguson EF Jr, Houston CH (1978) Iatrogenic supralevator fistula. South Med J 71(5):490– 495
Garg P (2016) Supralevator extension in fistula-in-ano is almost always in the intersphincteric
plane: easy solution for a complex disease. Dis Colon Rectum 59(5):e41–e42
Garg P (2017a) Comparing existing classifications of fistula-in-ano in 440 operated patients: is it
time for a new classification? Int J Surg 42:34–40
Garg P (2017b) Supralevator extrasphincteric fistula-in-ano are rare as supralevator extension is
almost always in the intersphincteric plane. World J Surg 41(9):2409–2410
Garg P (2017c) Transanal opening of intersphincteric space (TROPIS) – a new procedure to treat
high complex anal fistula. Int J Surg 40:130–134
Garg P (2018a) Garg classification for anal fistulas: is it better than existing classifications? – a
review. Indian J Surg 80(6):606–608
Garg P (2018b) Is fistulotomy still the gold standard in present era and is it highly underutilized?: an
audit of 675 operated cases. Int J Surg 56:26–30
Garg P (2018c) Understanding and treating supralevator fistula-in-ano: MRI analysis of 51 cases
and a review of literature. Dis Colon Rectum 61(5):612–621
Garg P (2019a) Anal fistula and pilonidal sinus disease coexisting simultaneously: an audit in a
cohort of 1284 patients. Int Wound J 16(5):1199–1205
Garg P (2019b) Comparison of preoperative and postoperative MRI after fistula-in-ano surgery:
lessons learnt from an audit of 1323 MRI at a single centre. World J Surg 43(6):1612–1622
Garg P (2020) Assessing validity of existing fistula-in-ano classifications in a cohort of 848 operated
and MRI assessed anal fistula patients – cohort study. Ann Med Surg 59:122–126
Garg P (2021) Transanal opening of the intersphincteric space (TROPIS): a novel sphincter-sparing
procedure to treat 325 high complex anal fistulas with long-term follow-up. Colorectal Dis
23(5):1213–1224
Garg P, Garg M, Das BR, Khadapkar R, Menon GR (2019) Perianal tuberculosis: lessons learned in
57 patients from 743 samples of histopathology and polymerase chain reaction and a systematic
review of literature. Dis Colon Rectum 62(11):1390–1400
Goligher JC (1961) Surgery of the anus, rectum and colon. Cassell, London, p 180
Gordon PH, Nivatvongs S (2007) Principles and practice of surgery for the colon, rectum and anus,
3rd edn. Informa Healthcare, New York
Lilius H (1968) Fistula-in-ano, an investigation of human foetal anal ducts and intramuscular glands
and a clinical study of 150 patients. Acta Chir Scand Suppl 383:7–88
Milligan F, Morgan C (1934) Surgical anatomy of the anal canal with special reference to ano-rectal
fistulae. Lancet 2:1150–1213
Morris J, Spencer JA, Ambrose NS (2000) MR imaging classification of perianal fistulas and its
implications for patient management. Radiographics 20(3):623–635. Discussion 635–637
Parks AG, Gordon PH, Hardcastle JD (1976) A classification of fistula-in-ano. Br J Surg 63(1):1–12
Steltzner F (1959) Die Atlorectalen Fisteln. Springer, Berlin
Whiteford MH, Kilkenny J III, Hyman N, Buie WD, Cohen J, Orsay C, Dunn G, Perry WB, Ellis
CN, Rakinic J, Gregorcyk S, Shellito P, Nelson R, Tjandra JJ, Newstead G (2005) Practice
parameters for the treatment of perianal abscess and fistula-in-ano (revised). Dis Colon Rectum
48(7):1337–1342
Part II
Clinical Features
Clinical Assessment of Anal Cryptoglandular Abscess and Fistula
Vincent de Parades, Nadia Fathallah, Elise Pommaret,
Lucas Spindler, Anne-Laure Rentien, Paul Benfredj, and
Manuel Aubert
Contents
1 Introduction . ............... .................................................................. 96
2 Types of Clinical Evaluation ................................... ............................. 96
3 Diagnosis ....................... ......................................... .................... 96
4 Topographic Evaluation .............................. ....................................... 98
4.1 The Cryptic Endoanal Primary Opening ............................................. 98
4.2 The Secondary Opening or Openings ................................................ 103
4.3 The Main Tract of the Fistula . . ....................................................... 103
4.4 Possible Purulent Collections ................... ...................................... 105
4.5 Possible Secondary Extensions ....................................................... 107
4.6 Evaluation of the Anatomy of the Anal Canal and of the Sphincter ................. 109
5 Conclusion ................................................................................... 109
References ............................ ............................................... ............ 110
7
Abstract
There has long been a consensus for a number of points concerning the clinical
assessment of cryptoglandular fistulae. This assessment is extremely useful for
the following purposes: (1) the diagnosis of anal cryptoglandular fistulae and
differential diagnosis; (2) topographic evaluation of the tract of the principal
fistula and possible purulent collection and secondary extensions; (3) evaluation
of the anatomy of the anal canal and of the sphincter apparatus. These diver se
elements are essential to ensure correct management of this disease, which is
challenging to treat due to the need to dry out the suppuration without exposing
the patient to a risk of subsequent anal incontinence. However, this assessment is
V. de Parades (*) · N. Fathallah · E. Pommaret · L. Spindler · A.-L. Rentien · P. Benfredj ·
M. Aubert
Service de Proctologie Médico-Chirurgicale, Groupe hospitalier Paris Saint-Joseph, Institut
Léopold Bellan, Paris, France
e-mail: vdeparades@ghpsj.fr; lhafit@ghpsj.fr; nfathallah@ghpsj.fr; epommaret@ghpsj.fr;
lspindler@ghpsj.fr; alrentien@ghpsj.fr; pbenfredj@ghpsj.fr; maubert@ghpsj.fr
© Springer Nature Switzerland AG 2022
C. Ratto et al. (eds.), Anal Fistula and Abscess, Coloproctology,
https://doi.org/10.1007/978-3-030-76670-2_9
95