Pankaj Garg, Dr1, Sachi Singhal, MBBS2, Sachin B Jamma, MBBS, MS3, Suresh Vasistha, MBBS, MS4. 1Garg Fistula Research Institute, 2Dayanand Medical College, Ludhiana, Punjab, India, 3Ashwini Rural Medical College, Kumbhari, Solapur, Maharashtra, India, 4Mangalam Hospital, Gurgaon, India
Objective: Classification is done to grade the disease according to severity and guide regarding its management. There are four classifications published for fistula-in-ano- Parks1(1976), St James university hospital(SJUH)2(2000) and Standard Practice Task Force (SPTF)3(2005) classification and a recent Garg4(2017) classification. Considering there is lot of confusion regarding management of fistula-in-ano, the objective of the study was to ascertain as which classification is most relevant and useful to the operating surgeon.
Method: The basis, methodology, utility(correlation with disease severity and guidance regarding disease management) and strong points of each classification were analyzed.
Results: All the classifications are compared in Figure-1.
Parks and SPTF were based on clinical experience, SJUH was MRI based and Garg was based on both clinical experience and MRI. Parks and SJUH did not correlate with disease severity whereas Garg and SPTF correlated well with disease severity. Whereas Parks, SJUH and SPTF were not validated by patient data, Garg classification was validated by patient data (440 patients). Whereas Parks, SJUH and SPTF had no role in the disease management, Garg classification guided the operating surgeon regarding the treatment of all types of anal fistulas. Garg grade I-II are simple fistulas and can be safely managed by fistulotomy without any risk to continence whereas Garg grade III-V are complex fistulas and fistulotomy should not be even attempted in these fistulas. The latter may be dealt with sphincter saving procedures like advancement flap, Anal Fistula Plug, LIFT or VAAFT. Thus this classification guides a general surgeon regarding the fistulas (grade I-II) which can be easily managed and the fistulas (grade III-V) that need to be referred to an expert(Figure-2).
Conclusion: Garg classification is a significant advancement over existing classification (Parks, SJUH & SPTF) with regard to accuracy and utility to the operating surgeon. It classifies the fistulas accurately as per disease severity as well as guides the operating surgeon regarding the disease management. Therefore, Garg classification should be used by radiologists and the surgeons.
(1) Parks A. G.et al(1976) A classification of fistula-in-ano. Br J Surg 63:1-12
(2) Morris J.et al(2000) MR imaging classification of perianal fistulas. Radiographics 20:623-635
(3) Whiteford M. H.et al(2005) Practice parameters for treatment of fistula-in-ano (revised). Dis Colon Rectum 48:1337-1342
(4) Garg P(2017) Comparing existing classifications of fistula-in-ano in 440 operated patients: Is it time for a new classification? Int J Surg 42:34-40
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93940
Program Number: P279
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster