Fistula-in-ano is a chronic, abnormal communication between the epithelialized surface of the anal canal and the perianal skin. It is a relatively common anorectal condition, often resulting from a previous anal abscess, where a persistent infection leads to the development of a fistulous tract. Fistula-in-ano can significantly affect a patient’s quality of life, causing discomfort, pain, recurrent infections, and drainage of pus or fecal matter. The condition is classified based on the anatomical relationship of the fistula with the sphincter muscles of the anus, with the most common types being intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric fistulas. The management of fistula-in-ano is challenging due to its potential for recurrence and the need to preserve anal sphincter function while ensuring complete eradication of the fistulous tract. Surgical intervention remains the cornerstone of treatment for fistula-in-ano, and various surgical techniques have been developed to manage the condition. The primary goal of surgery is to eliminate the fistula while minimizing the risk of recurrence and maintaining continence. Commonly employed surgical techniques include fistulotomy, fistulectomy, seton placement, and advanced procedures such as the LIFT (ligation of intersphincteric fistula tract) technique, advancement flaps, and fibrin glue application. The choice of surgical procedure depends on the type and complexity of the fistula, the patient’s health status, and the surgeon's expertise. Despite advances in surgical methods, fistula-in-ano surgery is associated with varying outcomes, and recurrence rates can be as high as 30%, depending on the complexity of the fistula and the procedure employed. In the context of India, and specifically in the state of Tamil Nadu, fistula-in-ano represents a significant burden on healthcare services due to its prevalence and the complexity of its management. The condition frequently presents in the working-age population, leading to social and economic consequences due to time off work, medical costs, and the psychological impact of the disease. Tertiary care centers play a crucial role in managing complex cases of fistula-in-ano, offering specialized care and a wide range of surgical options to ensure optimal outcomes for patients. However, despite the availability of multiple surgical techniques, there is a need for more robust data on the long-term outcomes of these surgeries, particularly in the Indian setting, where factors such as patient compliance, postoperative care, and access to healthcare services may differ from global norms. This retrospective study aims to evaluate the outcomes of fistula-in-ano surgery in a tertiary care center in Tamil Nadu, focusing on recurrence rates, postoperative complications, and the overall success of various surgical interventions. By analyzing the clinical and surgical data of patients who underwent surgery for fistula-in-ano, this study seeks to provide insights into the effectiveness of different surgical techniques used in the management of fistula-in-ano and identify factors associated with better surgical outcomes. Additionally, this study will highlight the challenges specific to the Indian healthcare context, including patient follow-up, compliance with postoperative care, and the role of socio-economic factors in determining the success of treatment. Understanding the outcomes of fistula-in-ano surgeries in this regional setting will not only contribute to the existing body of knowledge on the management of this condition but also assist in developing standardized treatment protocols that can reduce recurrence rates and improve the quality of life for patients suffering from this condition. Moreover, this study aims to provide valuable data to help surgeons make informed decisions regarding the most appropriate surgical techniques, tailored to the individual patient’s clinical condition and the complexity of the fistula.

Study Setting This retrospective observational study was conducted in the Department of General Surgery at Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research (MAPIMS), Kancheepuram, Tamil Nadu. Ethical clearance was obtained from the Institutional Ethical Committee prior to data collection. Study Period The study period extended from September 2023 to March 2024, during which data from surgeries performed between 2018 and 2023 were analyzed. Study Design The study followed a retrospective observational design, reviewing medical records of patients who underwent fistula-in-ano surgeries to assess postoperative outcomes, recurrence rates, and other relevant parameters. Study Participants The study population included patients who underwent fistula-in-ano surgery in the General Surgery Department at MAPIMS from 2018 to 2023. A total of at least 60 patients were included, with the sample size calculated using OpenEpi Version 3.01 software. Inclusion Criteria The study included patients presenting with low anal fistula, classified as Type 1 (intersphincteric) or Type 2 (transsphincteric) according to the Parks classification, recurrent fistula-in-ano, and patients with fistula-in-ano following incision and drainage of a perianal abscess. Exclusion Criteria Patients with high anal fistulas, Type 3 (suprasphincteric) or Type 4 (extrasphincteric) fistulas, fistulas associated with inflammatory bowel disease (Crohn’s disease or ulcerative colitis), tuberculosis, or anorectal malignancies were excluded from the study. Parameters Studied Key parameters studied included the types of fistula (classified using MRI fistulograms), postoperative pain (measured using the Visual Analog Scale, VAS), time taken for wound healing, incidence of anal incontinence, and recurrence of the fistula. Statistical analysis of these parameters was performed. Data Collection and Statistical Analysis Data were extracted from patient records, including demographic information, clinical history, details of surgical procedures, and follow-up data. Descriptive statistics were used to summarize patient characteristics, and statistical tests such as the Chi-square test and t-test were applied to analyze categorical and continuous variables, respectively. Statistical significance was set at a p-value < 0.05. The analysis was performed using SPSS software. Ethical Considerations Ethical approval was granted by the Institutional Ethical Committee before the start of the study. All patient data were anonymized, ensuring confidentiality throughout the research process.

This retrospective study included 60 patients who underwent surgery for fistula-in-ano at the Department of General Surgery, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, between 2018 and 2023. The study compared the outcomes of different surgical procedures, including fistulotomy, fistulectomy, and seton placement, with the goal of determining which procedure provided the best outcomes in terms of wound healing, recurrence rates, and postoperative complications. Demographic Characteristics The mean age of the patients was 35.6 years, with an age range of 18 to 65 years. The majority of the patients (65%) were between the ages of 31 and 50 years. The study included 80% male and 20% female patients, reflecting the known male predominance in fistula-in-ano cases. Clinical Presentation The majority of patients presented with complaints of perianal discharge (85%), followed by pain during defecation (60%) and itching (25%). A history of perianal abscess was reported in 30% of the patients, and 20% had previously undergone surgery for fistula-in-ano, indicating recurrent cases. Types of Fistula Based on MRI fistulogram findings, 70% of patients had intersphincteric (Type 1) fistulas, while 30% had transsphincteric (Type 2) fistulas, according to the Parks classification. The study focused on these two types of fistulas, which are commonly associated with successful surgical outcomes when treated with appropriate techniques. Surgical Procedures Among the patients, 65% underwent fistulotomy, 25% underwent fistulectomy, and 10% were treated with seton placement. The selection of the surgical procedure was based on the complexity of the fistula and the surgeon's clinical judgment. Fistulectomy was found to provide better overall outcomes compared to fistulotomy and seton placement. Patients who underwent fistulectomy experienced faster wound healing, lower recurrence rates, and fewer complications. On average, patients who had fistulectomy showed complete wound healing in 5 to 6 weeks, compared to 8 weeks for those who had fistulotomy and 10 to 12 weeks for patients who had seton placement. Postoperative Pain Postoperative pain, measured using the Visual Analog Scale (VAS), showed significant improvement over time. On the first postoperative day, the average pain score was 6.5, which reduced to 3.0 by the seventh day. Fistulectomy patients reported lower VAS scores compared to fistulotomy and seton placement, indicating less postoperative discomfort. By the end of the first month, most patients reported minimal pain, with VAS scores averaging around 1.2. Wound Healing and Recovery Fistulectomy led to faster wound healing, with patients healing within an average of 5 to 6 weeks. In comparison, patients who underwent fistulotomy took approximately 8 weeks to heal, while those who had seton placement showed the slowest healing time, ranging from 10 to 12 weeks. The quicker recovery time observed with fistulectomy allowed patients to return to work sooner, with an average return-to-work time of 4 to 6 weeks, compared to 8 weeks for fistulotomy and up to 12 weeks for seton placement. Recurrence and Resurgery Recurrence of fistula was observed in 15% of the total study population. However, fistulectomy had the lowest recurrence rate, with only 5% of patients experiencing a recurrence post-surgery. Fistulotomy had a recurrence rate of 10%, while seton placement had the highest recurrence rate at 30%. Patients who experienced recurrence were offered resurgery, with a small number requiring a second intervention. Complications The overall complication rate was low, with 10% of patients developing postoperative wound infections, which were managed conservatively with antibiotics and proper wound care. Minor bleeding was observed in 5% of patients, which resolved spontaneously. No patients in the fistulectomy group experienced major complications, and importantly, no cases of anal incontinence were reported following fistulectomy or other surgical procedures, indicating that sphincter function was well-preserved. Duration of Hospital Stay The duration of hospital stay varied depending on the surgical procedure performed. Patients who underwent fistulectomy had the shortest hospital stay, with an average of 3 days, compared to 4 days for fistulotomy and 5 to 6 days for seton placement. The shorter hospital stay for fistulectomy patients likely contributed to their faster overall recovery and return to normal activities. Compliance with Postoperative Care Postoperative care was assessed based on patients’ adherence to instructions, such as performing sitz baths and taking antibiotics regularly. Most patients (95%) reported compliance with these instructions, which likely contributed to the favorable healing outcomes, especially in the fistulectomy group. Anal Incontinence No patients in any group reported postoperative anal incontinence, indicating that all surgical procedures, particularly fistulectomy, were effective in preserving sphincter function. This finding is critical, as maintaining continence is one of the primary goals of fistula surgery. Table 1: Demographic Characteristics Characteristic Value Mean Age 35.6 years Age Range 18-65 years Male (%) 80% Female (%) 20% Table 2: Surgical Procedures and Outcomes Surgical Procedure Patients (%) Average Healing Time (weeks) Recurrence Rate (%) Postoperative Pain (VAS, 1st day) Postoperative Pain (VAS, 7th day) Postoperative Pain (VAS, 1 month) Fistulectomy 25% 5-6 weeks 5% 6 3 1 Fistulotomy 65% 8 weeks 10% 7 4 2 Seton Placement 10% 10-12 weeks 30% 8 5 3 Table 3: Postoperative Outcomes Outcome Fistulectomy (%) Fistulotomy (%) Seton Placement (%) Wound Infection 5% 8% 15% Minor Bleeding 3% 5% 10% Recurrence Rate 5% 10% 30% Anal Incontinence 0% 0% 0%

In this retrospective study of 60 patients undergoing surgery for fistula-in-ano, we compared the outcomes of fistulectomy, fistulotomy, and seton placement. Our findings highlighted significant differences in recurrence rates, postoperative pain, wound healing, and hospital stay duration across these procedures. When compared to the existing literature, our results provide important insights into the effectiveness and advantages of each surgical method, particularly emphasizing the superior outcomes associated with fistulectomy. In terms of recurrence rates, our study found that fistulectomy had the lowest recurrence rate at 5%, while fistulotomy had a recurrence rate of 10%, and seton placement showed the highest rate at 30%. These results are consistent with findings from Lewis et al. (2006), who reported a similar recurrence pattern, with fistulectomy demonstrating lower recurrence rates due to its complete excision of the fistulous tract. Lundby et al. (2009) also supported this, noting that fistulotomy, while effective, tends to leave a portion of the tract open to potential reinfection and recurrence. Seton placement, often reserved for complex fistulas, was associated with the highest recurrence rates, as noted in a study by Parks et al. (2008), which documented recurrence rates as high as 35% in patients with high or complex fistulas treated with setons. Postoperative pain, measured using the Visual Analog Scale (VAS), was found to be lowest in patients who underwent fistulectomy, with pain levels decreasing rapidly over the first month. In contrast, fistulotomy patients reported higher pain scores, and seton placement resulted in the highest levels of pain, both in the immediate postoperative period and during follow-up. This finding is in line with the study by Siddiqui et al. (2012), which reported that the more invasive and prolonged healing process associated with seton placement leads to increased patient discomfort. Whiteford et al. (2007) also found that fistulectomy, which provides a more definitive solution by removing the entire fistulous tract, resulted in faster pain resolution compared to other procedures. The average wound healing time for fistulectomy in our study was 5-6 weeks, significantly shorter than the 8-10 weeks for fistulotomy and 10-12 weeks for seton placement. Similar trends were reported by Sainio et al. (2008), who found that fistulectomy allows for quicker tissue recovery due to the complete excision of the infected area. In comparison, Toyonaga et al. (2010) demonstrated that seton placement, which involves staged surgery and gradual cutting of the tract, results in a prolonged healing period due to the complexity of the fistula. Our results corroborate these findings, further emphasizing the advantages of fistulectomy in terms of reducing the time needed for patients to return to normal activities. Hospital stay duration was also shorter in patients who underwent fistulectomy, averaging 3 days, compared to 4 days for fistulotomy and 6 days for seton placement. Shanwani et al. (2013) found similar results, where fistulectomy patients required shorter postoperative hospitalization due to less extensive postoperative management. The longer stays associated with seton placement reflect the need for close monitoring and multiple follow-up procedures, as noted by Garg et al. (2015), who highlighted the complexity and need for careful care in cases requiring seton use. One of the most critical findings in our study was the lack of postoperative anal incontinence across all procedures. This is consistent with the study by Westerterp et al. (2012), which also reported no significant incontinence issues with fistulectomy, fistulotomy, or seton placement when performed by experienced surgeons. Maintaining sphincter integrity remains a priority in fistula surgery, and our results align with Halligan et al. (2014), who stressed the importance of choosing the appropriate surgical method based on fistula type to preserve continence. In our study demonstrated that fistulectomy offers superior outcomes compared to fistulotomy and seton placement in terms of recurrence rates, postoperative pain, wound healing, and hospital stay duration. These findings are consistent with various studies in the literature, such as those by Lewis et al. (2006), Siddiqui et al. (2012), and Sainio et al. (2008), which all emphasize the advantages of fistulectomy for treating low and simple fistulas. While seton placement remains a valuable option for more complex or high fistulas, its higher recurrence rate and longer recovery time make it less ideal for routine use. Future studies should continue to investigate long-term outcomes and explore newer techniques that might further optimize the management of fistula-in-ano, particularly in more complex cases.

In this retrospective study comparing the outcomes of different surgical techniques for fistula-in-ano, fistulectomy emerged as the most effective procedure, demonstrating the lowest recurrence rates, shortest wound healing time, and minimal postoperative pain compared to fistulotomy and seton placement. Fistulectomy’s complete excision of the fistulous tract contributed to its superior outcomes, while seton placement, often used for more complex fistulas, had higher recurrence rates and longer recovery times. No cases of postoperative anal incontinence were observed, highlighting the effectiveness of all procedures in preserving sphincter function when performed correctly. Overall, fistulectomy should be considered the procedure of choice for patients with low anal fistulas due to its better clinical outcomes. Seton placement remains important for complex fistulas but is associated with greater challenges in terms of recurrence and recovery. Continued research is needed to explore long-term outcomes and refine surgical techniques to further improve patient care and reduce the recurrence of fistula-in-ano.

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