High and complex anal fistulas are iatrogenic in 99% of cases a prospective observational study of 48 cases
Ibrahim Falih Noori, Ahmed Falih NooriBackground:
High and complex anal fistulas remain one of the most difficult and challenging anorectal conditions to treat. While commonly considered an extension of cryptoglandular disease, growing evidence suggests that many are iatrogenic in origin.
Objective:
To prospectively analyze the etiology, surgical management, and outcomes of high and complex anal fistulas, with particular emphasis on the role of prior inappropriate anorectal surgery.
Methods:
A prospective observational study was conducted involving 48 consecutive patients with high or complex fistulas between February 2022 and January 2025. All patients underwent MRI fistulography and examination under anesthesia for classification. Surgical procedures were selected based on the type of fistula, continence status, and prior surgical procedures performed, and included the FiLaC technique, seton drainage, advancement flap, and staged fistulotomy. Patients were followed for 12–18 months to assess management outcomes in terms of healing, recurrence, continence, and patient satisfaction.
Results:
Almost all patients (97.9%) had prior anorectal surgery, most commonly abscess drainage (68%), fistulotomy and fistulectomy (19%), hemorrhoidectomy (6.25%), and lateral internal sphincterotomy (6.25%). High transsphincteric (52.15%) and suprasphincteric (31.2%) fistulas predominated. The overall healing rate in our series was recorded at 79.1%, while recurrence occurred in 20.8%, mainly in extrasphincteric tracts (37.5%). Minor incontinence was observed in 8.3%, particularly in patients with multiple-tract fistulas and multiple prior interventions. Major hemorrhage and sepsis were not recorded.
Conclusion:
Almost all high and complex fistulas in this series were iatrogenic. Appropriate initial management of anorectal abscesses and careful selection of sphincter-preserving procedures are cornerstones in the treatment of anorectal sepsis and fistulas to reduce recurrence and the subsequent development of complex anal fistulas.