LESSONS FROM 471 FISTULA-IN-ANO SURGERIES: A SEVEN-YEAR SINGLE-SURGEON CLINICAL AUDIT FROM SOUTH INDIA

Abstract

Abstract

Background:
Fistula-in-Ano remains a formidable surgical challenge owing to its tendency for recurrence, complex anatomy, fear of post operative incontinence and delayed wound healing. Regular clinical audits are vital to evaluate treatment outcomes and to refine surgical strategies.

Aim:
To analyze surgical outcomes of fistula-in-Ano managed by a single surgeon over seven years, with emphasis on recurrence, wound healing time and incontinence.

Methods:

This retrospective audit included a total of 471 patients operated between March 2021 and October 2025. Among them, 14 patients were lost to follow-up, and 42 patients were found to be tuberculosis (TB) positive during evaluation or follow-up.

For analytical purposes, two cohorts were compared based on the time of practice implementation:

• Pre-Implementation Cohort: 57 patients (March 2021–March 2022), with 4 recurrences (19%).


• Post-Implementation Cohort: 400 patients (April 2022–October 2025), with 17 recurrences (4.4%).

Treatment strategies included fistulogram, biopsy, curettage, TROPIS, fistulectomy, abscess drainage, and sphincter repair, tailored to fistula type and complexity. Outcomes were assessed for recurrence, wound healing time, and complications.

Results:

A total of 457 patients with fistula-in-ano were operated between March 2021 and August 2025, comprising 338 males and 119 females. The majority of cases (90%) were classified as complex fistulas. The overall recurrence rate for the entire cohort was 5.2% (21 patients). When analyzed by study period, Pre-Implementation Cohort (March 2021 – March 2022) showed a higher recurrence rate of 19%, whereas Post-Implementation Cohort (April 2022 – October 2025) demonstrated a marked reduction to 4.4%, reflecting refinement of surgical technique and improved case selection over time.

In this a total of 83 patients (18.1%) underwent redo surgery. Among these, 21 cases (4.6%) represented recurrences from the surgeon’s own earlier operations, while 62 cases (13.5%) were referred from outside hospitals following failed primary procedures. Of the referred group, a few patients did not attend follow-up or declined redo surgery; the remaining underwent individualized management using techniques such as TROPIS, fistulotomy, tunnel fistulectomy, seton placement, and primary sphincter repair, achieving complete wound healing in all operated cases.

Among the 457 patients included in the analysis, 42 patients (9.2%) were tuberculosis (TB) positive. One patient developed a complex ano-ureteral fistula secondary to HIV disease, and another patient had biopsy-proven malignancy due to Non-Hodgkin lymphoma. Posterior fistulas were the most common type (50%), followed by transsphincteric (24%) and supralevator (21%) variants. Postoperative wound healing occurred as follows: 60% of patients healed within 2 months, 20% within 4 months, and 20% within 6 months, with minimal morbidity. Importantly, anal continence was preserved in all patients in our study period.

Over seven years, progressive refinement of sphincter-sparing reduced recurrence from 19% to 4.4%, with complete continence preservation. Systematic evaluation, early imaging, and individualized surgical planning remain key to optimizing outcomes in fistula-in-ano.