Re-routing of the tract in the treatment of high anal fistula: A single-center experience  

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Because of their complexity, this study aimed to assess the re-routing role in the high anal fistulae treatment, as well as to assess recurrence and incontinence, and determine whether re-routing of the tract is a good option for treating high anal fistulae. Methods: It is a prospective interventional study that was conducted on 83 patients with high perianal fistula, ranging in age from 18 to 72 years old, of both genders. All cases were assigned to history taking, laboratory investigations, clinical examination (general examination and local examination), and magnetic resonance imaging [MRI] for objective delineation of the fistulous tractand its attribution with the anal sphincters. Results: · After a minimum follow-up period of 9 months, 5 cases (6.02%) experienced recurrence. Mild incontinence was reported in 4 patients (4.8%), while 4 patients (4.8%) developed infection. Additionally, tractgangrene was observed in 2 patients (2.41%). · In multivariate regression, suprasphincteric fistulae, and infection were independent predictors for recurrence. Conclusion: The re-routing procedure is a feasible and safe surgical option for managing high transsphincteric perianal fistulae. It is associated with low postoperative complication rates, including short-term recurrence. It combines the advantages of fistulotomy and sphincter-preserving fistula surgery. However, further studies involving a large number of suprasphincteric fistula cases are needed to evaluate the efficacy of the re-routing technique in treating such fistulae. Re-routing Tract Treatment High Anal Fistula Figures Figure 1 Figure 2 Introduction High anal fistulae represent a complex form of perianal disease, often involving deep structures and significant challenges in diagnosis and treatment. The distinction between low and high anal fistulae is critical in guiding both surgical management and the prediction of outcomes [1] . Various classifications have been proposed to classify these fistulae as low or high, simple or complex, or intersphincteric, transsphincteric, suprasphincteric, or extrasphincteric based on their anatomy [2] . High fistulae tend to have more intricate anatomy and are associated with higher rates of recurrence and complications, requiring specialized care [1] The primary treatment for anal fistula is surgical intervention. The optimal treatment strategy is to eliminate the infected lesion, facilitate the closure of the fistula, and ensure adequate drainage while avoiding the risk of injury to the anal sphincters. [3] The actual hazard associated with these fistulae is the potential for incontinence in the case that a significant section of the external sphincter is inadvertently severed or injured [4] . Re-routing is a transposition technique that was introduced by Mann and Clifton in 1985 for the treatment of high anal and anorectal fistulae. [5] . The procedure entails the immediate restoration of the external sphincter and the re-routing of the extra sphincteric portion of the tract into an intersphincteric position. The external sphincter is effectively recovered at a later date, and the newly positioned intersphincteric fistula is eventually addressed. [6] . This study's purpose is to evaluate the role of re-routing the tract in high anal fistulae treatment, as well as to assess recurrence and incontinence and determine if re-routing of the tract is a good choice in the treatment of high anal fistula. Patients and Methods This study is the first to be based on a large number of high anal fistula cases. It is a prospective interventional study was carried out on 83 high perianal fistula cases aged from 18 to 72 years old, of both sexes, from September 2021 to September 2024. Ethical approval Study approved by the Assiut Faculty of Medicine Institutional Review Board (Approval number: 17101821) at Assiut University, Egypt and was conducted in the general surgery department at Assiut University Hospitals. Written informed consent was obtained from all patients included in the study. The study was registered with ClinicalTrials.gov (Registration number: NCT05476146) on July 27, 2022, and was conducted in accordance with the Declaration of Helsinki. Study inclusion and exclusion criteria: This study included all patients with high cryptoglandular anal fistulae, whether de novo or recurrent. The exclusion criteria were as follows: Cases involving low anal fistulae, defined as those where the fistula tract is located in the lower third of the external anal sphincter. Patients with fistulae secondary to other pathologies, such as malignancy, inflammatory bowel disease, trauma, or radiation. Patients who exhibited incontinence during the preoperative evaluation were also excluded. Data collection Each case was examined for the following: history-taking (personal history, current complaint, analysis of each complaint, review of other GIT symptoms, review of other systems, current medical comorbidities, and previous surgical history);clinical examination (general examination and local examination; entire perineum, digital rectal examination, association between the anorectal ring and the tract position before the cases received anesthesia and anoscopy). Laboratory investigations and magnetic resonance imaging fistulogram were required for all cases, for objective description of the fistulous tract and its association with the anal sphincters. Preoperative preparation The night prior to the operation, patients were advised to undergo a brief mechanical bowel preparation that involved a single rectal enema and a restriction of oral consumption to eliminate fluids 12 hours prior to the operation. The surgical technique: All patients underwent the two-stage re-routing operation under spinal anesthesia when the patient was in the lithotomy position. The site of the operation was properly prepared and draped. Before the skin incision, a broad-spectrum antibiotic was commenced (IV ceftriaxone 1 gm) in addition to IV metronidazole (500 mg). The first stage Coring out of the fistulous tract was done via cutting and coagulation diathermy. The surgical dissection was stopped at the point where the tract traversed the external anal sphincter. Then, a circumanal incision was made at the anal verge, centered on the point where the fistulous tract pierced the external sphincter. The intersphincteric space was entered and dissected until we felt the fistulous tract. The fistulous tract was dissected from the external sphincter by simple muscle splitting, and it was pulled to the intersphincteric space. The opening in the external sphincter was obliterated by a few interrupted stitches using absorbable suture material (Vicryl 2/0 sutures). If the tract was too long, its distal portion was excised. No seton was inserted in the fistulous tract. The second stage: It was carried out 6-8 weeks after the first stage. The second stage was also conducted in the lithotomy position and under spinal anesthesia. The previously transposed intersphincteric fistula was probed and laid open. This entailed division of the internal sphincter’s most lower fibers. The tract was curetted, and a small cutback was done to ensure proper drainage and sound healing. Postoperative care: The cases were moved to the recovery room and then to the internal surgical ward. Analgesia was maintained by IV paracetamol and IV non-steroidal anti-inflammatory analgesic,if needed. All cases were discharged after the second postoperative day. The patients commenced on oral antibiotics (metronidazole 500 mg three times daily and ciprofloxacin 500 mg twice daily for five days). Analgesia was achieved by oral paracetamol (1 gm / 8 hours) and oral non-steroidal anti-inflammatory analgesic. Patients were taught about home wound care. Post-discharge recommendations: Diet: Encouraging a high-fiber diet. Hygiene: After each bowel movement, soak the anal orifice in a warm sitz bath for five minutes using a moist cotton pad. Follow-up: All patients were evaluated twice weekly for 1 week, weekly for 1 month, and monthly for nine months after the second stage. The time needed for complete wound healing was recorded in all patients. The same policy of postoperative care was followed after every stage of surgery. Postoperative incontinence was evaluated via the Wexner questionnaire after the second procedure. The Cleveland Clinic Fecal Incontinence Severity Scoring System, also known as the Wexner score, is a fecal incontinence score that ranges from 0 to 20, with 0 reflecting ideal continence and 20 representing complete incontinence. [7] . That score was calculated for all patients three, six, and nine months after the second stage, keeping in consideration that all patients had a preoperative score of 0, as we already excluded patients who had incontinence during preoperative evaluation. That score was assessed at three-, six-, and nine-month follow-up visits. Table (1): The Jorge-Wexner incontinence score Type of incontinence Frequency Never Rarely Sometimes Usually Always Solid 0 1 2 3 4 Liquid 0 1 2 3 4 Gas 0 1 2 3 4 Wears pad 0 1 2 3 4 Lifestyle alteration 0 1 2 3 4 Never = 0; Rarely = <1/month; Sometimes = 1/month; Usually = 1/week; Always = >1/day The recurrence rate was the primary outcome, and the secondary outcomes were incontinence, wound infection, duration until complete wound healing, and operative time. Statistical analysis SPSS v28 (IBM©, Armonk, NY, USA) was employed to conduct the statistical analysis. The normality of the data distribution was assessed using the Shapiro-Wilk test and histograms. The quantitative parametric data were analyzed utilizing an unpaired student t-test and presented as the mean and standard deviation (SD). The Mann-Whitney test was employed to analyze quantitative non-parametric data, which were presented as the median and interquartile range (IQR). The chi-square test or Fisher's exact test was employed to analyze qualitative variables, which were presented as frequency and percentage (%) when appropriate. The relationship between a dependent variable and one (univariate) or more independent variables (multivariate) was also estimated using logistic regression. Statistical significance was defined as a two-tailed P value that was less than 0.05. Results The mean age of the cases was 43.36 years (range, 18 – 72). Men had a higher prevalence than women, as the former constituted 62.7% of the study participants. Their mean body mass index (BMI) was 29.34 kg/m 2 (range, 23 – 37). Among the included cases, 84.3% (70 cases) of patients presented with de novo high anal fistulae, while 15.7% (13 cases) had recurrent anal fistulae. Regarding their pre-existing medical comorbidities, hypertension (HTN) and diabetes mellitus (DM) were present in 10.8% and 7.2% of cases, respectively. In addition, compensated liver cirrhosis was present in three cases (3.61%). Smokers represented 45.23% of the study population. ( Table 2). The disease duration ranged between one and twelve months (median = 7). Perianal discharge was reported in all cases. Other complaints included perianal pain, dysdefecation, and dermatitis, which were reported in 69.88%, 38.55%, and 18.07% of cases, respectively. Table 2 Most of the detected fistulae were of the transsphincteric type (89.2%), while the remaining cases were of the suprasphincteric type. The majority of patients (88.0%) had a single external opening, whereas the remaining 10 cases had multiple openings. Among these, the openings in 4 cases were close to each other and were included in the tissue core during dissection. The openings in the other 6 cases were not close to each other; for these 6 cases, the additional openings of them were low fistulae and managed with lay-open fistulotomy. The fistula opening location was anterior in 51.81% of cases and posterior in the remaining 48.19% ( Table 2). Table 2: Patients’ demographic data, presentation, and disease criteria n=83 Age (years) 42.37 ± 13.10 Gender Male 52(62.7%) Female 31(37.3%) BMI (kg/m 2 ) 29.34 ± 4.37 Smoking 38 (45.23%) DM 6(7.2%) HTN 9(10.8) Compensated liver cirrhosis 3 (3.61%) Disease duration (months) 7 (3 – 10) Patient complaint Perianal discharge 83 (100%) Pain 58 (69.88%) Dysdefecation 32 (38.55%) Dermatitis 15 (18.07%) Fistula type Transsphincteric 74(89.2%) Suprasphincteric 9(10.8%) Number of external openings Single 73(88.0%) Multiple 10 (12.0%) Site of external openings Anterior 43 (51.81%) Posterior 40 (48.19%) Previous fistula surgery Denovo fistula Recurrent fistula 70(84.3%) 13(15.7%) Data are presented as mean ± SD, median (IQR), or frequency (%). BMI: body mass index, DM: diabetes mellitus, HTN: hypertension. The operative time of the 1 st stage ranged between 45 and 90 minutes (mean = 68.13), while the hospitalization period ranged between one and two days (mean = 1.2). The duration to complete wound healing had a mean value of 5.49 weeks (range, 4-7) and delayed healing was encountered in 16 cases (19.28%). Regarding the 2 nd stage, the mean operative time was 21.51 minutes (range, 15-30). The duration of hospitalization in the second stage is one day. Complete wound healing occurred in 3.1 weeks (range 2-4), and delayed healing occurred in 14 cases (16.87%) ( Table 3). Table 3: Operative data and hospital stay after 1 st and 2 nd stage (n=83) 1 st stage 2 nd stage Operative time (min) 68.13 ± 14.5 21.51 ± 4.8 Time to wound healing (weeks) 5.49 ± 1.12 3.1 ± 0.84 Delayed healing 16 (19.28%) 14 (16.87%) Hospitalization period (days) 1.2 ± 0.3 1.07 ± 0.08 Data are presented as mean ± SD or frequency (%). Postoperative infection occurred in only four cases (after the first stage). One of these infections was superficial, and it was managed by frequent dressing, proper hygiene, and IV antibiotics, but the other 3 cases presented with recurrence later on. Two patients (2.41%) developed tract gangrene that was managed by tract excision and completed staged re-routing later on. No patients developed postoperative bleeding. Recurrence after finishing all stages of the operation occurred in five patients (6.02%). Two patients refused further intervention while the other three patients developed recurrent low transsphincteric fistulae, were seen in the second stage, and were treated with lay-open fistulotomy ( Table 4). Table 4: Postoperative complications and recurrence n=83 Infection 4 (4.8%) Gangrene 2 (2.41%) Bleeding 0 (0%) Recurrence 5 (6.02%) Minor incontinence 4 (4.8 %) Data are presented as frequency (%). Statistical analysis revealed a significant difference in the Wexner score during follow-up compared to the preoperative value. However, that difference was clinically irrelevant as no patients had a score of more than 4. Table 5 Table 5: Changes in Wexner score during follow-up (n=83) Baseline 3 months 6 months 9 months P value 0 (0 – 0) 4 (3 – 4) 3 (2 – 3) 2 (1 – 3) <0.001* Data are presented as median (IQR). *: significant as P value ≤ 0.05. The postoperative continence status and Wexner score did not differ from the preoperative continence status and score in 79 patients. Four patients (4.82%) experienced minor postoperative incontinence in the form of gas incontinence in three patients and staining of the underwear in one patient. Univariate analysis for prognostic factors of recurrence revealed that diabetes, supra-sphincteric fistula, and infection were independent predictors of recurrence. However, age, gender, BMI, smoking, hypertension, liver disease, duration of disease, the number of fistula openings (single or multiple), the site of the external opening, previous fistula surgery, operative time, and wound healing outcomes were not identified as significant predictors ( Table 6) . In multivariate regression, suprasphincteric fistula and infection were independent predictors for recurrence ( Table 7). Table 6: Univariate regression analysis for prediction of recurrence Predictors Univariate regression P value OR 95% CI for OR Lower Upper Gender Male R Female 0.296 2.679 0.422 17.002 Age 0.618 1.018 0.950 1.090 BMI 0.626 1.055 0.851 1.307 Hypertension 0.507 2.187 0.217 22.042 Diabetes 0.026 * 9.733 1.310 72.319 Liver disease 0.999 NA NA NA Smoking 0.260 0.277 0.030 2.592 Fistula type: High TR R Suprasphincteric 0.001 * 58.400 5.543 625.497 Infection <0.001 * 115.500 8.053 1656.492 Bleeding 1.000 NA NA NA Disease duration 0.097 0.766 0.558 1.050 Site of external openings Anterior 0.707 1.425 0.226 9.004 Posterior R Number of external openings:- Single Multiple R 0.074 5.833 0.844 40.307 Previous fistula surgery:- Denovo fistula Recurrent fistula R 0.999 NA NA NA 1 st stage operative time 0.539 1.020 0.957 1.088 1 st stage wound healing 0.318 0.653 0.284 1.505 2 nd stage operative time 0.471 0.929 0.759 1.136 2 nd stage wound healing 0.266 0.585 0.227 1.505 OR: Odds ratio CI: Confidence interval LL: Lower limit UL: Upper Limit Table 7: Multivariate regression analysis for prediction of recurrence Predictors Multivariate regression P value OR 95% CI for OR Lower Upper Diabetes Mellitus 0.122 13.481 0.497 365.632 Supra sphincteric type 0.032 * 23.355 1.305 418.115 Infection 0.032 * 55.547 1.401 2203.014 OR: Odds ratio CI: Confidence interval LL: Lower limit UL: Upper Limit Hosmer and Lemeshow Test 2( p)=1.467(0.226) Discussion A fistula is referred to as an unusual communication between two epithelialized surfaces. Anal fistulae are characterized by an atypical communication between the anorectal canal and perianal epidermis. [8] . Laying open of the fistulous tract is the classic operation for anal fistula management that is associated with minimal recurrence [9,10] . The low recurrence rate after fistulotomy is probably because of the internal opening elimination [11]. This allows the fistulous tract to heal from the inside out. Additionally, by opening the tract, any infection or abscess can drain freely, reducing the risk of recurrence, a benefit not typically seen in sphincter-preserving surgeries. In these procedures, the internal opening is merely blocked if fibrin glue or fistula plug is used, covered in mucosal advancement flap operation, stitched in video assisted anal fistula treatment and ligation of the intersphincteric fistula tract techniques, or burned in operations using LASER technology. The reported rate of recurrence after anal fistula surgery is between 3 and 57%, with varying rates among different procedures [12] . The non-eradicated internal fistula opening can reopen at any time and become infected, an event that cannot be confidently avoided in the inherently contaminated medium of the anal canal [18] . It is thus not astonishing that the recurrence rate is higher after sphincter-saving fistula surgery as compared with fistulotomy [13,14]. Despite the low recurrence rate after fistulotomy, this operation's major disadvantage is the inevitable division of part of the anal sphincters, which can lead to postoperative fecal incontinence [9,15,16,17]. It thus seems that recurrence and incontinence are two faces of the same coin that accompany surgery for anal fistula; the more that is done to avoid one, the more it is likely to get the other [17]. The fistula tract re-routing is a minimally sphincter-sacrificing procedure in which the extrasphincteric portion of the tract is transposed into an intersphincteric position. Fistulotomy of the transposed intersphincteric tract is then performed at a later stage [5] . Mann and Clifton were the first to describe that method. [5] This study is the first to discuss this technique with such a large number of cases (83 cases) and also analyzes the recurrence causes. In the current study, most of the detected fistulae were of the transsphincteric type (89%) while the remaining cases had suprasphincteric ones. In agreement with our results, Abou-Zeid et al. [18] stated that transsphincteric fistula was the most common type (68.5%) while the remaining cases had the suprasphincteric type (31.5%).In addition, Omar and his colleagues reported that transsphincteric fistula was the most common type (93.33%). Other types included horseshoe and suprasphincteric fistulae (3.33% for each) [19] Our findings revealed no incidence of postoperative bleeding in our patients. Postoperative infection occurred in only four cases (5%); one of these cases was superficial and managed by repeated dressing, proper hygiene, and intravenous antibiotics, but the other three cases developed recurrence. In a previous similar study, the incidence of the same complication was 5% after the re-routing procedure. [20] ,which is near our findings. In the current study, two patients developed postoperative tract gangrene. Gangrene occurs because the mobilized fistulous tract was thinned out extensively to allow it to pass through the small slit in the external sphincter before it was transposed to the intersphincteric space. This probably jeopardized the vascularity of the tract which became gangrenous in its distal part. Abou-Zeid et al. [18] reported that gangrene of the mobilized rerouted tract occurred in one patient (1.85%). Our findings revealed that the healing period after the first stage ranged between 4 and 7 weeks (28-42 days) and the healing period after the second stage between 2-4 weeks (14-28 days), In the study conducted by Ouf et al., the healing period had a mean value of 43.4 days (range, 35 –53 days). The authors did not specify whether it is the period needed for a specific stage or all stages. Also, they did not mention a specific definition of complete healing. [20] . Differences in the healing rate between studies could be explained by patient factors and the incidence of postoperative complications. Our finding revealed that the postoperative continence status and Wexner score did not differ from the preoperative continence status and score in 79 patients. Four patients (4.82%) experienced minor postoperative incontinence in the form of gas incontinence in three patients and staining of the underwear in one patient. Two patients improved after training the pelvic floor muscles with regular exercises, and the other two did not improve through the follow-up period. However, that difference was clinically irrelevant, as no patients had a score of more than 4. Likewise, Abou Zaid et al. [18] reported that the postoperative continence status and Wexner score did not differ from the preoperative continence status and score in their enrolled 54 patients. In the same context, Maqsood and Rasikh [21] reported the incidence of flatus incontinence in only one patient after re-routing for high fistulae (2.7%), while Ouf et al. [20] denied the incidence of that complication after the same procedure (0%). Other authors reported a relatively higher incidence of the same adverse event. For instance, Ibrahim et al. reported that postoperative incontinence occurred in only 10% of cases after the re-routing procedure (three cases). Two of them had only gas incontinence while the remaining case had stool incontinence. [22] In our study, postoperative recurrence was encountered in 6% of cases. In accordance with our findings, Ouf and his coworkers [20] reported that recurrence was encountered in 10% of patients who had the same procedure for high perianal fistula, which is near our findings. In contrast, other studies reported lower recurrence rates after the same intervention in such cases. According to the study of Ibrahim et al. [22] recurrence occurred in only two cases after the same procedure (6.7%). Univariate analysis for prognostic factors of recurrence revealed that diabetes, supra- sphincteric fistula, and infection were independent predictors of recurrence. However, age, gender, BMI, smoking, hypertension, liver disease, duration of disease, the number of fistula openings (single or multiple), the site of the external opening, previous fistula surgery, operative time, and wound healing outcomes were not identified as significant predictors. In multivariate regression, suprasphincteric fistula and infection were independent predictors . Z. Mei and colleagues identified factors such as prior anal surgery, high transsphincteric fistula, undetected internal openings, and multiple fistulous tracts as being associated with an increased risk of recurrence [12]. However, these factors did not align with the findings of our study. While J. Jordan et al. concluded that suprasphincteric fistulae are the greatest risk factors for recurrence and incontinence , making them the most challenging to treat [11] . In our study, we assessed five cases of fistula recurrence. Among these, one was a high transphincteric fistula, while the other four were suprasphincteric. Notably, three of the suprasphincteric fistulae developed postoperative infections following the first stage of surgery. Suprasphincteric fistulae require particularly careful and precise dissection. We hypothesize that minor, unnoticed punctures occurred during the dissection of the tract, leading to the spread of infection. This likely happened through the external sphincter opening, which had been cored during the procedure. The infection, originating from these small punctures, contributed to the formation of recurrent fistulae. These issues were observed early in the study, during the learning curve phase. In subsequent cases, we modified our approach by ensuring a more careful dissection of the tract within a core of healthy tissue. This technique was effective in preventing tract gangrene and small punctures and thereby reducing the risk of infection and recurrence. We recommend that more studies involving more cases from different surgical centers should be performed in the future; these studies should assess long-term follow-up. Limitations : Our study lacks intermediate and long-term follow-up, as well as small sample size of patients with suprasphincteric fistulae. Conclusions The re-routing procedure is a feasible and safe surgical option for managing high transphincteric perianal fistulae. It is associated with low postoperative complication rates, including short-term recurrence. It combines the advantages of fistulotomy and sphincter-preserving fistula surgery. However, further studies involving a larger number of suprasphincteric fistula cases are needed to evaluate the efficacy of the re-routing technique in treating such fistulae. Declarations Acknowledgment I would like to extend my heartfelt gratitude to Professor Dr Ahmed Abdelaziz Abou-Zeid, for his invaluable participation and support throughout this work. His insights, feedback, and collaboration greatly enriched this study, and his contributions are deeply appreciated. Financial support and sponsorship: Nil Conflict of Interest: Nil Funding : No funding was received for this study. Author Contribution Mahmoud Mohamed , Dr. Mahmoud Refaat, and Dr. Ragai contributed to the data analysis and interpretation of the results.Mahmoud Mohamed , Dr. Mahmoud Refaat, and Dr. Ragai were involved in data collection and the design of the study.Dr. Mahmoud Refaat and mahmoud mohamed conducted the surgery and preparred figuresDr mahmoud refaat and Dr. Jamal was responsible for reviewing the statistical analysis and data, as well as performing a comprehensive review of the manuscript.All authors have reviewed the manuscript and approved the final version. References Gaertner W, Hagerman G, Steele S, et al. Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum.2022;65(8):966-978. Shi R, Gu J. Classification and Diagnosis of Anal Fistula. In: Shi R, Zheng L, editors. Diagnosis and Treatment of Anal Fistula. 5. Singapore: Springer Singapore; 2021. p. 89-99. Balciscueta Z, Uribe N, García-Granero Á, Balciscueta I, Espín-Basany E, Pellino G. Evidences for Optimal Surgical Management of Anal Fistulae and Abscesses. In: Ratto C, Parello A, Litta F, De Simone V, Campennì P, editors. Anal Fistula and Abscess. 4. Cham: Springer International Publishing; 2020. p. 1-29. Garg P, Sodhi SS, Garg N. Management of complex cryptoglandular anal fistula: challenges and solutions. Clin Exp Gastroenterol. 2020;4:555-67. Mann CV, Clifton MA. Re‐routing of the track for the treatment of high anal and anorectal fistulae. Br J Surg. 1985;72:134-7. Abou-Zeid AA, AbdEl-Wahab EH, abd Almoneim Alshafeiy MS, Ebied EF. Re-routing as a minimal sphincter sacrificing procedure for the management of horseshoe perianal fistula: a prospective observational study. Egypt J Surg. 2022;41:314-8. Nevler A. The epidemiology of anal incontinence and symptom severity scoring. Gastroenterol Rep. 2014;2:79-84. Włodarczyk M, Włodarczyk J, Sobolewska-Włodarczyk A, Trzciński R, Dziki Ł, Fichna J. Current concepts in the pathogenesis of cryptoglandular perianal fistula. Int J Med Res. 2021;49:30-9 Abbas MA, Jackson CH, Haigh PI. Predictors of outcome for anal fistula surgery. Arch Surg 2011; 146:1011–1016. Toyonaga T, Matsushima M, Kiriu T, Sogawa N, Kanyama H, Matsumura N. Factors affecting continence after fistulotomy for intersphincteric fistula-inano. Int J Colorectal Dis 2007; 22:1071–1075. Jordán J, Roig JV, García-Armengol J, García-Granero E, Solana A, Lledó S. Risk factors for recurrence and incontinence after anal fistula surgery. Colorectal Dis 2010; 12:254–260. Mei Z, Wang Q, Zhang Y, Liu P, Ge M, Du P, et al .Risk factors for recurrence after anal fistula surgery: A meta- analysis. International journal of surgery. 2019; 69:153-64. Tyler KM, Aarons CB, Sentovich SM. Successful sphincter-sparing surgery for all anal fistulae. Dis Colon Rectum 2007; 50:1535–1539. Sirikurnpiboon S, Awapittaya B, Jivapaisarnpong P. Ligation of intersphincteric fistula track and its modification: results from treatment of complex fistula. World J Gastrointest Surg 2013; 5:123–128. Göttgens KW, Janssen PT, Heemskerk J, Van Dielen FM, Konsten LM, Lettinga T, et al. Long-term outcome of low perianal fistulae treated by fistulotomy: a multicenter study. Int J Colorectal Dis 2015; 30:213–219. van Tets WF, Kuijpers HC. Continence disorders after anal fistulotomy. Dis Colon Rectum 1994; 37:1194–1197. Cavanaugh M, Hyman N, Osler T. Fecal incontinence severity index after fistulotomy. Dis Colon Rectum 2002; 45:349–353. Abou-Zeid AA, Halim SA, Elghamrini Y. The use of re-routing operation in the treatment of high arching transsphincteric and suprasphincteric anal fistula: an observational study. Egypt J Surg. 2021;40:180-5. Omar W, Alqasaby A, Abdelnaby M, Youssef M, Shalaby M, Abdel-Razik MA, et al. Drainage Seton Versus External Anal Sphincter-Sparing Seton After Re-routing of the Fistula Track in the Treatment of Complex Anal Fistula: A Randomized Controlled Trial. Diseases of the Colon & Rectum. 2019;62(8):980-7. Ouf TIA, Abdel-Wanees WA-A, Abd Elsamia YM, Abdelrazek AM. Comparative study between staged re-routing and rectal advancement flap with curettage of fistula track in treatment of horse shoe perianal fistula. Ain Shams Med J. 2020;71:689-99. Maqsood SCR, Rasikh A. Re-routing of high/recurrent anal fistula without seton. Pak Armed Forces Med J. 2012;62:510-13. Ibrahim M, Yasser M, Salem A. Retrospective evaluation of outcome of re-routing technique in management of horseshoe perianal fistula, single institution experience. Med J Cairo Univ. 2021;89:505-11. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Jul, 2025 Read the published version in Techniques in Coloproctology → Version 1 posted Editorial decision: Accepted 06 Jun, 2025 Reviews received at journal 16 Apr, 2025 Reviewers agreed at journal 07 Apr, 2025 Reviews received at journal 06 Apr, 2025 Reviewers agreed at journal 06 Apr, 2025 Reviewers invited by journal 05 Apr, 2025 Submission checks completed at journal 26 Mar, 2025 First submitted to journal 24 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5738577","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":439705809,"identity":"50fabe30-f209-4c7d-8062-5da6022bb966","order_by":0,"name":"Mahmoud Refaat Shehata","email":"","orcid":"","institution":"Assiut University Hospitals","correspondingAuthor":false,"prefix":"","firstName":"Mahmoud","middleName":"Refaat","lastName":"Shehata","suffix":""},{"id":439705810,"identity":"1b3c35b3-b555-41c7-b8cb-7165c954cb5b","order_by":1,"name":"Mahmoud Mohamed Mohamed Abdelghany","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYHACA+Y/FTY89u0NILYFcVoYeM6kyRjwHACxJYjUwtt22MZAIgHEIUKLbnvzxgeSbcw85pLPr274USDBwN/enYBXi9mZY8UGBufYeCxn55Td7AE6TOLM2Q34tdzIMZNIKOPhYbidk3aDB6jFQCKXoBbzHwfYJHgYbp5Ju/mHSC1mjA1tBjwGN9iP3SbOFqBfpBnOJPBI9uSw3ZYxkOAh7JfjzRs/M1T8t+dnP/7s5ps/NnL87b34tSABHgMwSaxyEGB/QIrqUTAKRsEoGEEAAF58R9vpuUPsAAAAAElFTkSuQmCC","orcid":"","institution":"Assiut University Hospitals","correspondingAuthor":true,"prefix":"","firstName":"Mahmoud","middleName":"Mohamed Mohamed","lastName":"Abdelghany","suffix":""},{"id":439705811,"identity":"d737018c-1168-477a-85e6-53f1d932ccfe","order_by":2,"name":"Gamal Abdel-Hamid Ahmed Eid","email":"","orcid":"","institution":"Assiut University Hospitals","correspondingAuthor":false,"prefix":"","firstName":"Gamal","middleName":"Abdel-Hamid Ahmed","lastName":"Eid","suffix":""},{"id":439705812,"identity":"bbe8b756-c5b0-4cd0-b70f-8395ec390fb3","order_by":3,"name":"Ragai Sobhi Hanna","email":"","orcid":"","institution":"Assiut University Hospitals","correspondingAuthor":false,"prefix":"","firstName":"Ragai","middleName":"Sobhi","lastName":"Hanna","suffix":""}],"badges":[],"createdAt":"2024-12-31 02:38:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5738577/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5738577/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10151-025-03179-3","type":"published","date":"2025-07-24T15:57:45+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80295232,"identity":"82c14e53-7da5-4585-85bb-9c57a91044f0","added_by":"auto","created_at":"2025-04-10 08:33:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1554961,"visible":true,"origin":"","legend":"\u003cp\u003eA: External opening before surgical intervention. B: Interposition of the tract in the intersphincteric groove. C: The second stage, lay open the intersphincteric tract.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5738577/v1/5fcf2752155f199ca1b91059.png"},{"id":80295233,"identity":"9394ff3f-b2cc-44a1-9612-cf04d74c1124","added_by":"auto","created_at":"2025-04-10 08:33:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1268311,"visible":true,"origin":"","legend":"\u003cp\u003eA: Dissection of the tract up to its entrance through the external sphincter. B: Second stage preoperative. C: Lay open fistulotomy.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5738577/v1/381112e79a58c7196a014b19.png"},{"id":87756851,"identity":"5ca02bd2-c413-4c9e-b139-557a47652eb7","added_by":"auto","created_at":"2025-07-28 16:09:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3715784,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5738577/v1/d362da38-32e6-41ec-ba3b-85a3380d61dd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Re-routing of the tract in the treatment of high anal fistula: A single-center experience ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHigh anal fistulae represent a complex form of perianal disease, often involving deep structures and significant challenges in diagnosis and treatment. The distinction between low and high anal fistulae is critical in guiding both surgical management and the prediction of outcomes \u003csup\u003e[1]\u003c/sup\u003e. Various classifications have been proposed to classify these fistulae as low or high, simple or complex, or intersphincteric, transsphincteric, suprasphincteric, or extrasphincteric based on their anatomy\u003csup\u003e[2]\u003c/sup\u003e. High fistulae tend to have more intricate anatomy and are associated with higher rates of recurrence and complications, requiring specialized care\u003csup\u003e[1]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe primary treatment for anal fistula is surgical intervention. The optimal treatment strategy is to eliminate the infected lesion, facilitate the closure of the fistula, and ensure adequate drainage while avoiding the risk of injury to the anal sphincters.\u003csup\u003e[3]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe actual hazard associated with these fistulae is the potential for incontinence in the case that a significant section of the external sphincter is inadvertently severed or injured \u003csup\u003e[4]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRe-routing is a transposition technique that was introduced by Mann and Clifton in 1985 for the treatment of high anal and anorectal fistulae. \u003csup\u003e[5]\u003c/sup\u003e. The procedure entails the immediate restoration of the external sphincter and the re-routing of the extra sphincteric portion of the tract into an intersphincteric position. The external sphincter is effectively recovered at a later date, and the newly positioned intersphincteric fistula is eventually addressed.\u003csup\u003e[6]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study's purpose is to evaluate the role of re-routing the tract in high anal fistulae treatment, as well as to assess recurrence and incontinence and determine if re-routing of the tract is a good choice in the treatment of high anal fistula.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eThis study is the first to be based on a large number of high anal fistula cases. It is a \u0026nbsp;prospective interventional study was carried out on 83 high perianal fistula cases aged from 18 to 72 years old, of both sexes, from September 2021 to September 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy approved by the Assiut Faculty of Medicine Institutional Review Board (Approval number: 17101821) at Assiut University, Egypt and was conducted in the general surgery department at Assiut University Hospitals. Written informed consent was obtained from all patients included in the study. The study was registered with ClinicalTrials.gov (Registration number: NCT05476146) on July 27, 2022, and was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy inclusion and exclusion criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study included all patients with high cryptoglandular anal fistulae, whether de novo or recurrent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe exclusion criteria were as follows:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eCases involving low anal fistulae, defined as those where the fistula tract is located in the lower third of the external anal sphincter.\u003c/li\u003e\n \u003cli\u003ePatients with fistulae secondary to other pathologies, such as malignancy, inflammatory bowel disease, trauma, or radiation.\u003c/li\u003e\n \u003cli\u003ePatients who exhibited incontinence during the preoperative evaluation were also excluded.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach case was examined for the following: history-taking (personal history, current complaint, analysis of each complaint, review of other GIT symptoms, review of other systems, current medical comorbidities, and previous surgical history);clinical examination (general examination and local examination; entire perineum, digital rectal examination, association between the anorectal ring and the tract position before the cases received anesthesia and anoscopy). Laboratory investigations and magnetic resonance imaging fistulogram were required for all cases, for objective description of the fistulous tract and its association with the anal sphincters.\u003c/p\u003e\n\u003cp\u003ePreoperative preparation\u003c/p\u003e\n\u003cp\u003eThe night prior to the operation, patients were advised to undergo a brief mechanical bowel preparation that involved a single rectal enema and a restriction of oral consumption to eliminate fluids 12 hours prior to the operation.\u003c/p\u003e\n\u003cp\u003eThe surgical technique:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll patients underwent the two-stage re-routing operation under spinal anesthesia when the patient was in the lithotomy position. The site of the operation was properly prepared and draped. Before the skin incision, a broad-spectrum antibiotic was commenced (IV ceftriaxone 1 gm) in addition to IV metronidazole (500 mg).\u003c/p\u003e\n\u003cp\u003eThe first stage\u003c/p\u003e\n\u003cp\u003eCoring out of the fistulous tract was done via cutting and coagulation diathermy. The surgical dissection was stopped at the point where the tract traversed the external anal sphincter. Then, a circumanal incision was made at the anal verge, centered on the point where the fistulous tract pierced the external sphincter. The intersphincteric space was entered and dissected until we felt the fistulous tract. The fistulous tract was dissected from the external sphincter by simple muscle splitting, and it was pulled to the intersphincteric space. The opening in the external sphincter was obliterated by a few interrupted stitches using absorbable suture material (Vicryl 2/0 sutures). If the tract was too long, its distal portion was excised. No seton was inserted in the fistulous tract.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe second stage:\u003c/p\u003e\n\u003cp\u003eIt was carried out 6-8 weeks after the first stage. The second stage was also conducted in the lithotomy position and under spinal anesthesia. The previously transposed intersphincteric fistula was probed and laid open. This entailed division of the internal sphincter\u0026rsquo;s most lower fibers. The tract was curetted, and a small cutback was done to ensure proper drainage and sound healing.\u003c/p\u003e\n\u003cp\u003ePostoperative care:\u003c/p\u003e\n\u003cp\u003eThe cases were moved to the recovery room and then to the internal surgical ward. Analgesia was maintained by IV paracetamol and IV non-steroidal anti-inflammatory analgesic,if needed. All cases were discharged after the second postoperative day. The patients commenced on oral antibiotics (metronidazole 500 mg three times daily and ciprofloxacin 500 mg twice daily for five days). Analgesia was achieved by oral paracetamol (1 gm / 8 hours) and oral non-steroidal anti-inflammatory analgesic. Patients were taught about home wound care.\u003c/p\u003e\n\u003cp\u003ePost-discharge recommendations:\u003c/p\u003e\n\u003cp\u003eDiet: Encouraging a high-fiber diet. Hygiene: After each bowel movement, soak the anal orifice in a warm sitz bath for five minutes using a moist cotton pad.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollow-up:\u003c/p\u003e\n\u003cp\u003eAll patients were evaluated twice weekly for 1 week, weekly for 1 month, and monthly for nine months after the second stage. The time needed for complete wound healing was recorded in all patients. The same policy of postoperative care was followed after every stage of surgery. Postoperative incontinence was evaluated via the Wexner questionnaire after the second procedure. The Cleveland Clinic Fecal Incontinence Severity Scoring System, also known as the Wexner score, is a fecal incontinence score that ranges from 0 to 20, with 0 reflecting ideal continence and 20 representing complete incontinence. \u003csup\u003e[7]\u003c/sup\u003e. That score was calculated for all patients three, six, and nine months after the second stage, keeping in consideration that all patients had a preoperative score of 0, as we already excluded patients who had incontinence during preoperative evaluation. That score was assessed at three-, six-, and nine-month follow-up visits.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 623px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable (1): The Jorge-Wexner incontinence score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 255px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eType of incontinence\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 368px;\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eRarely\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eSometimes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eUsually\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eAlways\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eSolid\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eLiquid\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eGas\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eWears pad\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eLifestyle alteration\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 623px;\"\u003e\n \u003cp\u003eNever = 0; Rarely = \u0026lt;1/month; Sometimes = \u0026lt;1/week but \u0026gt; 1/month; Usually = \u0026lt;1/day but \u0026gt;1/week; Always = \u0026gt;1/day\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe recurrence rate was the primary outcome, and the secondary outcomes were incontinence, wound infection, duration until complete wound healing, and operative time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStatistical analysis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSPSS v28 (IBM\u0026copy;, Armonk, NY, USA) was employed to conduct the statistical analysis. The normality of the data distribution was assessed using the Shapiro-Wilk test and histograms. The quantitative parametric data were analyzed utilizing an unpaired student t-test and presented as the mean and standard deviation (SD). The Mann-Whitney test was employed to analyze quantitative non-parametric data, which were presented as the median and interquartile range (IQR). The chi-square test or Fisher\u0026apos;s exact test was employed to analyze qualitative variables, which were presented as frequency and percentage (%) when appropriate. The relationship between a dependent variable and one (univariate) or more independent variables (multivariate) was also estimated using logistic regression. Statistical significance was defined as a two-tailed P value that was less than 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe mean age of the cases was 43.36 years (range, 18 \u0026ndash; 72). Men had a higher prevalence than women, as the former constituted 62.7% of the study participants. Their mean body mass index (BMI) was 29.34 kg/m\u003csup\u003e2\u003c/sup\u003e (range, 23 \u0026ndash; 37). \u0026nbsp;Among the included cases, 84.3% (70 cases) of patients presented with de novo high anal fistulae, while 15.7% (13 cases) had recurrent anal fistulae. Regarding their pre-existing medical comorbidities, hypertension (HTN) and diabetes mellitus (DM) were present in 10.8% and 7.2% of cases, respectively. In addition, compensated liver cirrhosis was present in three cases (3.61%). Smokers represented 45.23% of the study population. (\u003cstrong\u003eTable 2).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe disease duration ranged between one and twelve months (median = 7). Perianal discharge was reported in all cases. Other complaints included perianal pain, dysdefecation, and dermatitis, which were reported in 69.88%, 38.55%, and 18.07% of cases, respectively. \u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost of the detected fistulae were of the transsphincteric type (89.2%), while the remaining cases were of the suprasphincteric type. The majority of patients (88.0%) had a single external opening, whereas the remaining 10 cases had multiple openings. Among these, the openings in 4 cases were close to each other and were included in the tissue core during dissection. The openings in the other 6 cases were not close to each other; for these 6 cases, the additional openings of them were low fistulae and managed with lay-open fistulotomy.\u003c/p\u003e\n\u003cp\u003eThe fistula opening location was anterior in 51.81% of cases and posterior in the remaining 48.19% (\u003cstrong\u003eTable 2).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2: Patients\u0026rsquo; demographic data, presentation, and disease criteria\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 44.7271%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=83\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 44.7271%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e42.37 \u0026plusmn; 13.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.2574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e52(62.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 23.2574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e31(37.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 44.7271%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e29.34 \u0026plusmn; 4.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 44.7271%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e38 (45.23%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 44.7271%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e6(7.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 44.7271%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHTN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e9(10.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 44.7271%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCompensated liver cirrhosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e3 (3.61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 44.7271%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisease duration (months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e7 (3 \u0026ndash; 10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 44.7271%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"4\" style=\"width: 21.5013%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient complaint\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23.2574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerianal discharge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e83 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.2574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e58 (69.88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.2574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDysdefecation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e32 (38.55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23.2574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Dermatitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e15 (18.07%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 21.5013%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23.2574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 21.5013%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFistula type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTranssphincteric\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e74(89.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuprasphincteric\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e9(10.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 21.5013%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 21.5013%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of external openings\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSingle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e73(88.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultiple\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e10 (12.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 21.5013%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 21.5013%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSite of external openings\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnterior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e43 (51.81%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePosterior\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e40 (48.19%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 21.5013%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious fistula surgery \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.2574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDenovo fistula\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eRecurrent fistula\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.1288%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 70(84.3%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 13(15.7%) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as mean \u0026plusmn; SD, median (IQR), or frequency (%). BMI: body mass index, DM: diabetes mellitus, HTN: hypertension.\u003c/p\u003e\n\u003cp\u003eThe operative time of the 1\u003csup\u003est\u003c/sup\u003e stage ranged between 45 and 90 minutes (mean = 68.13), while the hospitalization period ranged between one and two days (mean = 1.2). The duration to complete wound healing had a mean value of 5.49 weeks (range, 4-7) and delayed healing was encountered in 16 cases (19.28%). Regarding the 2\u003csup\u003end\u003c/sup\u003e stage, the mean operative time was 21.51 minutes (range, 15-30). The duration of hospitalization in the second stage is one day. Complete wound healing occurred in 3.1 weeks (range 2-4), and delayed healing occurred in 14 cases (16.87%) (\u003cstrong\u003eTable 3).\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3: Operative data and hospital stay after 1\u003csup\u003est\u003c/sup\u003e and 2\u003csup\u003end\u003c/sup\u003e stage (n=83)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003csup\u003est\u003c/sup\u003e stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003csup\u003end\u003c/sup\u003e stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperative time (min)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e68.13 \u0026plusmn; 14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e21.51 \u0026plusmn; 4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to wound healing (weeks)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e5.49 \u0026plusmn; 1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e3.1 \u0026plusmn; 0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDelayed healing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e16 (19.28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e14 (16.87%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospitalization period (days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e1.2 \u0026plusmn; 0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e1.07 \u0026plusmn; 0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as mean \u0026plusmn; SD or frequency (%).\u003c/p\u003e\n\u003cp\u003ePostoperative infection occurred in only four cases (after the first stage). One of these infections was superficial, and it was managed by frequent dressing, proper hygiene, and IV antibiotics, but the other 3 cases presented with recurrence later on. Two patients (2.41%) developed tract gangrene that was managed by tract excision and completed staged re-routing later on. No patients developed postoperative bleeding. Recurrence after finishing all stages of the operation occurred in five patients (6.02%). Two patients refused further intervention while the other three patients developed recurrent low transsphincteric fistulae, were seen in the second stage, and were treated with lay-open fistulotomy (\u003cstrong\u003eTable 4).\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 4: Postoperative complications and recurrence\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=83\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInfection\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e4 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGangrene\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e2 (2.41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBleeding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e5 (6.02%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Minor incontinence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e4 (4.8 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as frequency (%).\u003c/p\u003e\n\u003cp\u003eStatistical analysis revealed a significant difference in the Wexner score during follow-up compared to the preoperative value. However, that difference was clinically irrelevant as no patients had a score of more than 4. \u003cstrong\u003eTable 5\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 5: Changes in Wexner score during follow-up (n=83)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e0 (0 \u0026ndash; 0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e4 (3 \u0026ndash; 4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e3 (2 \u0026ndash; 3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e2 (1 \u0026ndash; 3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as median (IQR). *: significant as P value \u0026le; 0.05.\u003c/p\u003e\n\u003cp\u003eThe postoperative continence status and Wexner score did not differ from the preoperative continence status and score in 79 patients. Four patients (4.82%) experienced minor postoperative incontinence in the form of gas incontinence in three patients and staining of the underwear in one patient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; Univariate analysis for prognostic factors of recurrence revealed that diabetes, supra-sphincteric fistula, and infection were independent predictors of recurrence. However, age, gender, BMI, smoking, hypertension, liver disease, duration of disease, the number of fistula openings (single or multiple), the site of the external opening, previous fistula surgery, operative time, and wound healing outcomes were not identified as significant predictors (\u003cstrong\u003eTable\u003c/strong\u003e \u003cstrong\u003e6)\u003c/strong\u003e. In multivariate regression, suprasphincteric fistula and infection were independent predictors for recurrence (\u003cstrong\u003eTable 7).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 6: Univariate regression analysis for prediction of recurrence\u003c/p\u003e\n\u003cdiv align=\"center\" style='margin:0in;text-align:right;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003ctable style=\"border-collapse: collapse;border: none;width: 421px;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width:125.7pt;border:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003ePredictors\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width:189.7pt;border:solid windowtext 1.0pt;border-left:none;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eUnivariate regression\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:45.1pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eP value\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width:48.2pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eOR\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width:96.4pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e95% CI for OR\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eLower\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eUpper\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:125.7pt;border-top:none;border-left:solid windowtext 1.0pt;border-bottom:none;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eGender\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.1pt;border:none;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border:none;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border:none;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border:none;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:125.7pt;border-top:none;border-left:solid windowtext 1.0pt;border-bottom:none;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;font-size:16px;font-family:\"Times New Roman\",serif;margin-left:14.2pt;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eMale\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.1pt;border:none;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border:none;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border:none;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border:none;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:125.7pt;border:solid windowtext 1.0pt;border-top: none;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;font-size:16px;font-family:\"Times New Roman\",serif;margin-left:14.2pt;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eFemale\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.1pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.296\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e2.679\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.422\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e17.002\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:125.7pt;border:solid windowtext 1.0pt;border-top: none;padding:0in 0in 0in 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style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n 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style='margin:0in;text-align:left;font-size:16px;font-family:\"Times New Roman\",serif;margin-left:14.2pt;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eMultiple\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.1pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eR\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.074\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e5.833\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.844\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e40.307\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 125.7pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in;height: 1pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0in;text-align:left;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003ePrevious fistula surgery:-\u003c/span\u003e\u003c/strong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp; \u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:left;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Denovo fistula\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:left;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Recurrent fistula\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.1pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eR\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.999\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eNA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eNA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eNA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:125.7pt;border:solid windowtext 1.0pt;border-top: none;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e1\u003csup\u003est\u003c/sup\u003e stage operative time\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.1pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.539\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e1.020\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.957\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e1.088\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:125.7pt;border:solid windowtext 1.0pt;border-top: none;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e1\u003csup\u003est\u003c/sup\u003e stage wound healing\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.1pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.318\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.653\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.284\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e1.505\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:125.7pt;border:solid windowtext 1.0pt;border-top: none;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e2\u003csup\u003end\u003c/sup\u003e stage operative time\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.1pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.471\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.929\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.759\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e1.136\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:125.7pt;border:solid windowtext 1.0pt;border-top: none;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e2\u003csup\u003end\u003c/sup\u003e stage wound healing\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.1pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.266\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.585\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.227\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.2pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e1.505\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eOR: Odds ratio \u0026nbsp; CI: Confidence interval \u0026nbsp; \u0026nbsp;LL: Lower limit \u0026nbsp; UL: Upper Limit\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 7: Multivariate regression analysis for prediction of recurrence\u003c/p\u003e\n\u003cdiv align=\"center\" style='margin:0in;text-align:right;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003ctable style=\"border-collapse: collapse;border: none;width: 348px;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width:105.3pt;border:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003ePredictors\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width:155.95pt;border:solid windowtext 1.0pt;border-left:none;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eMultivariate regression\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:40.1pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eP value\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width:34.6pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eOR\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width:81.25pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e95% CI for OR\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:39.15pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eLower\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:42.1pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eUpper\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:105.3pt;border-top:none;border-left:solid windowtext 1.0pt;border-bottom:none;border-right:solid windowtext 1.0pt;padding: 0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom: 1.0pt;margin-left:0in;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003eDiabetes Mellitus\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:40.1pt;border:none;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.122\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:34.6pt;border:none;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e13.481\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:39.15pt;border:none;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e0.497\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:42.1pt;border:none;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e365.632\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:105.3pt;border:solid windowtext 1.0pt;border-bottom: none;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom: 1.0pt;margin-left:0in;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:40.1pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:34.6pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:39.15pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:42.1pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:105.3pt;border:solid windowtext 1.0pt;border-top: none;background:#F7CAAC;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom: 1.0pt;margin-left:0in;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";color:black;'\u003eSupra\u003c/span\u003e\u003c/strong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";color:black;'\u003e\u0026nbsp;\u003cstrong\u003esphincteric\u003c/strong\u003e \u003cstrong\u003etype\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:40.1pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #F7CAAC;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";color:black;'\u003e0.032\u003c/span\u003e\u003c/strong\u003e\u003csup\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";color:black;'\u003e*\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:34.6pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #F7CAAC;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";color:black;'\u003e23.355\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:39.15pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#F7CAAC;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";color:black;'\u003e1.305\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:42.1pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background: #F7CAAC;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";color:black;'\u003e418.115\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 105.3pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(247, 202, 172);padding: 0in;height: 1pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0in;text-align:left;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom: 1.0pt;margin-left:0in;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";color:black;'\u003eInfection\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:40.1pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#F7CAAC;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";color:black;'\u003e0.032\u003c/span\u003e\u003c/strong\u003e\u003csup\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";color:black;'\u003e*\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:34.6pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#F7CAAC;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";color:black;'\u003e55.547\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:39.15pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#F7CAAC;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";color:black;'\u003e1.401\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:42.1pt;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;background:#F7CAAC;padding:0in 0in 0in 0in;height:1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;font-size:16px;font-family:\"Times New Roman\",serif;margin-top:2.0pt;margin-right:0in;margin-bottom:1.0pt;margin-left:0in;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\";color:black;'\u003e2203.014\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eOR: Odds ratio \u0026nbsp; CI: Confidence interval \u0026nbsp; \u0026nbsp;LL: Lower limit \u0026nbsp; UL: Upper Limit\u003c/p\u003e\n\u003cp\u003eHosmer and Lemeshow Test\u003cspan dir=\"RTL\"\u003e2(\u003c/span\u003ep)=1.467(0.226)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eA fistula is referred to as an unusual communication between two epithelialized surfaces. Anal fistulae are characterized by an atypical communication between the anorectal canal and perianal epidermis. \u003csup\u003e[8]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eLaying\u0026nbsp;open of the fistulous tract is the classic operation for anal fistula management that is associated with minimal recurrence \u003csup\u003e[9,10]\u003c/sup\u003e. The low recurrence rate after fistulotomy is probably because of the internal opening elimination \u003csup\u003e[11].\u0026nbsp;\u003c/sup\u003eThis allows the fistulous tract to heal from the inside out. Additionally, by opening the tract, any infection or abscess can drain freely, reducing the risk of recurrence, a benefit not typically seen in sphincter-preserving surgeries.\u003csup\u003e\u0026nbsp;\u0026nbsp;\u003c/sup\u003eIn these procedures, the internal opening is merely blocked if fibrin glue or fistula plug is used, covered in mucosal advancement flap operation, stitched in video assisted anal fistula treatment and ligation of the intersphincteric fistula tract techniques, or burned in operations using LASER technology. \u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eThe reported rate of recurrence after anal fistula surgery is between 3 and 57%, with varying rates among different procedures\u003csup\u003e[12]\u003c/sup\u003e.\u0026nbsp;\u003cs\u003eThe non-eradicated internal fistula opening can reopen at any time and become infected, an event that cannot be confidently avoided in the inherently contaminated medium of the anal canal\u003csup\u003e[18]\u003c/sup\u003e\u003c/s\u003e. It is thus not astonishing that the recurrence rate is higher after sphincter-saving fistula surgery as compared with fistulotomy \u003csup\u003e[13,14].\u003c/sup\u003e Despite the low recurrence rate after fistulotomy, this operation\u0026apos;s major disadvantage is the inevitable division of part of the anal sphincters, which can lead to postoperative fecal incontinence \u003csup\u003e[9,15,16,17].\u003c/sup\u003e It thus seems that recurrence and incontinence are two faces of the same coin that accompany surgery for anal fistula; the more that is done to avoid one, the more it is likely to get the other \u003csup\u003e[17].\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe fistula tract re-routing is a minimally sphincter-sacrificing procedure in which the extrasphincteric portion of the tract is transposed into an intersphincteric position. Fistulotomy of the transposed intersphincteric tract is then performed at a later stage \u003csup\u003e[5]\u003c/sup\u003e. Mann and Clifton were the first to describe that method. \u003csup\u003e[5]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThis study is the first to discuss this technique with such a large number of cases (83 cases) and also analyzes the recurrence causes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the current study, most of the detected fistulae were of the transsphincteric type (89%) while the remaining cases had suprasphincteric ones. In agreement with our results, Abou-Zeid et al. \u003csup\u003e[18]\u003c/sup\u003estated that transsphincteric fistula was the most common type (68.5%) while the remaining cases had the suprasphincteric type (31.5%).In addition, Omar and his colleagues reported that transsphincteric fistula was the most common type (93.33%). Other types included horseshoe and suprasphincteric fistulae (3.33% for each) \u003csup\u003e[19]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOur findings revealed no incidence of postoperative bleeding in our patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Postoperative infection occurred in only four cases (5%); one of these cases was superficial and managed by repeated dressing, proper hygiene, and intravenous antibiotics, but the other three cases developed recurrence. In a previous similar study, the incidence of the same complication was 5% after the re-routing procedure.\u003csup\u003e[20]\u003c/sup\u003e,which is near our findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the current study, two patients developed postoperative tract gangrene. Gangrene occurs because\u0026nbsp;the\u0026nbsp;mobilized fistulous tract was thinned out extensively to allow it to pass through the small slit in the external sphincter before it was transposed to the intersphincteric space. This probably jeopardized the vascularity of the tract which became gangrenous in its distal part. Abou-Zeid et al. \u003csup\u003e[18]\u003c/sup\u003ereported that gangrene of the mobilized rerouted tract occurred in one patient (1.85%).\u003c/p\u003e\n\u003cp\u003eOur findings revealed that the healing period after the first stage ranged between 4 and 7 weeks (28-42 days) and the healing period after the second stage between 2-4 weeks (14-28 days), In the study conducted by Ouf et al., the healing period had a mean value of 43.4 days (range, 35 \u0026ndash;53 days). The authors did not specify whether it is the period needed for a specific stage or all stages. Also, they did not mention a specific definition of complete healing. \u003csup\u003e[20]\u003c/sup\u003e. Differences in the healing rate between studies could be explained by patient factors and the incidence of postoperative complications. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur finding revealed that the postoperative continence status and Wexner score did not differ from the preoperative continence status and score in 79 patients. Four patients (4.82%) experienced minor postoperative incontinence in the form of gas incontinence in three patients and staining of the underwear in one patient. Two patients improved after training the pelvic floor muscles with regular exercises, and the other two did not improve through the follow-up period. However, that difference was clinically irrelevant, as no patients had a score of more than 4. Likewise, Abou Zaid et al. \u003csup\u003e[18]\u003c/sup\u003e reported that the postoperative continence status and Wexner score did not differ from the preoperative continence status and score in their enrolled 54 patients.\u003c/p\u003e\n\u003cp\u003eIn the same context, Maqsood and Rasikh \u003csup\u003e[21]\u003c/sup\u003ereported the incidence of flatus incontinence in only one patient after re-routing for high fistulae (2.7%), while Ouf et al. \u003csup\u003e[20]\u003c/sup\u003e denied the incidence of that complication after the same procedure (0%).\u003c/p\u003e\n\u003cp\u003eOther authors reported a relatively higher incidence of the same adverse event. For instance, Ibrahim et al. reported that postoperative incontinence occurred in only 10% of cases after the re-routing procedure (three cases). Two of them had only gas incontinence while the remaining case had stool incontinence.\u003csup\u003e[22]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; In our study, postoperative recurrence was encountered in 6% of cases. In accordance with our findings, Ouf and his coworkers\u003csup\u003e[20]\u003c/sup\u003e reported that recurrence was encountered in 10% of patients who had the same procedure for high perianal fistula, which is near our findings.\u003c/p\u003e\n\u003cp\u003eIn contrast, other studies reported lower recurrence rates after the same intervention in such cases. According to the study of Ibrahim et al.\u003csup\u003e[22]\u003c/sup\u003erecurrence occurred in only two cases after the same procedure (6.7%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;Univariate analysis for prognostic factors of recurrence revealed that diabetes, supra-\u003c/p\u003e\n\u003cp\u003esphincteric fistula, and infection were independent predictors of recurrence. However, age, gender, BMI, smoking, hypertension, liver disease, duration of disease, the number of fistula openings (single or multiple), the site of the external opening, previous fistula surgery, operative time, and wound healing outcomes were not identified as significant predictors. In multivariate regression, suprasphincteric fistula and infection were independent predictors\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; Z. Mei and colleagues identified factors such as prior anal surgery, high transsphincteric fistula, undetected internal openings, and multiple fistulous tracts as being associated with an increased risk of recurrence \u003csup\u003e[12].\u003c/sup\u003e However, these factors did not align with the findings of our study.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eWhile J. Jordan et al. concluded that suprasphincteric fistulae are the greatest risk factors for recurrence and incontinence\u003cstrong\u003e,\u003c/strong\u003e making them the most challenging to treat \u003csup\u003e[11]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;In our study, we assessed five cases of fistula recurrence. Among these, one was a high transphincteric fistula, while the other four were suprasphincteric. Notably, three of the suprasphincteric fistulae developed postoperative infections following the first stage of surgery. Suprasphincteric fistulae require particularly careful and precise dissection. We hypothesize that minor, unnoticed punctures occurred during the dissection of the tract, leading to the spread of infection. This likely happened through the external sphincter opening, which had been cored during the procedure. The infection, originating from these small punctures, contributed to the formation of recurrent fistulae. These issues were observed early in the study, during the learning curve phase. In subsequent cases, we modified our approach by ensuring a more careful dissection of the tract within a core of healthy tissue. This technique was effective in preventing tract gangrene and small punctures and thereby reducing the risk of infection and recurrence.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;We recommend that more studies involving more cases from different surgical centers should be performed in the future; these studies should assess long-term follow-up.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;\u003cstrong\u003eLimitations\u003c/strong\u003e: Our study lacks intermediate and long-term follow-up, as well as small sample size of patients with suprasphincteric fistulae.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe re-routing procedure is a feasible and safe surgical option for managing high transphincteric perianal fistulae. It is associated with low postoperative complication rates, including short-term recurrence. It combines the advantages of fistulotomy and sphincter-preserving fistula surgery. However, further studies involving a larger number of suprasphincteric fistula cases are needed to evaluate the efficacy of the re-routing technique in treating such fistulae.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;I would like to extend my heartfelt gratitude to Professor Dr Ahmed Abdelaziz Abou-Zeid, for his invaluable participation and support throughout this work. His insights, feedback, and collaboration greatly enriched this study, and his contributions are deeply appreciated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial support and sponsorship:\u003c/strong\u003e Nil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e Nil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: No funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMahmoud Mohamed , Dr. Mahmoud Refaat, and Dr. Ragai contributed to the data analysis and interpretation of the results.Mahmoud Mohamed , Dr. Mahmoud Refaat, and Dr. Ragai were involved in data collection and the design of the study.Dr. Mahmoud Refaat and mahmoud mohamed conducted the surgery and preparred figuresDr mahmoud refaat and Dr. Jamal was responsible for reviewing the statistical analysis and data, as well as performing a comprehensive review of the manuscript.All authors have reviewed the manuscript and approved the final version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGaertner W, Hagerman G, Steele S, et al. Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum.2022;65(8):966-978.\u003c/li\u003e\n\u003cli\u003eShi R, Gu J. Classification and Diagnosis of Anal Fistula. In: Shi R, Zheng L, editors. Diagnosis and Treatment of Anal Fistula. 5. Singapore: Springer Singapore; 2021. p. 89-99.\u003c/li\u003e\n\u003cli\u003eBalciscueta Z, Uribe N, Garc\u0026iacute;a-Granero \u0026Aacute;, Balciscueta I, Esp\u0026iacute;n-Basany E, Pellino G. Evidences for Optimal Surgical Management of Anal Fistulae and Abscesses. In: Ratto C, Parello A, Litta F, De Simone V, Campenn\u0026igrave; P, editors. Anal Fistula and Abscess. 4. Cham: Springer International Publishing; 2020. p. 1-29.\u003c/li\u003e\n\u003cli\u003eGarg P, Sodhi SS, Garg N. Management of complex cryptoglandular anal fistula: challenges and solutions. Clin Exp Gastroenterol. 2020;4:555-67.\u003c/li\u003e\n\u003cli\u003eMann CV, Clifton MA. Re‐routing of the track for the treatment of high anal and anorectal fistulae. Br J Surg. 1985;72:134-7.\u003c/li\u003e\n\u003cli\u003eAbou-Zeid AA, AbdEl-Wahab EH, abd Almoneim Alshafeiy MS, Ebied EF. Re-routing as a minimal sphincter sacrificing procedure for the management of horseshoe perianal fistula: a prospective observational study. Egypt J Surg. 2022;41:314-8.\u003c/li\u003e\n\u003cli\u003eNevler A. The epidemiology of anal incontinence and symptom severity scoring. Gastroenterol Rep. 2014;2:79-84.\u003c/li\u003e\n\u003cli\u003eWłodarczyk M, Włodarczyk J, Sobolewska-Włodarczyk A, Trzciński R, Dziki Ł, Fichna J. Current concepts in the pathogenesis of cryptoglandular perianal fistula. Int J Med Res. 2021;49:30-9\u003c/li\u003e\n\u003cli\u003eAbbas MA, Jackson CH, Haigh PI. Predictors of outcome for anal fistula surgery. Arch Surg 2011; 146:1011\u0026ndash;1016.\u003c/li\u003e\n\u003cli\u003eToyonaga T, Matsushima M, Kiriu T, Sogawa N, Kanyama H, Matsumura N. Factors affecting continence after fistulotomy for intersphincteric fistula-inano. Int J Colorectal Dis 2007; 22:1071\u0026ndash;1075.\u003c/li\u003e\n\u003cli\u003eJord\u0026aacute;n J, Roig JV, Garc\u0026iacute;a-Armengol J, Garc\u0026iacute;a-Granero E, Solana A, Lled\u0026oacute; S. Risk factors for recurrence and incontinence after anal fistula surgery. Colorectal Dis 2010; 12:254\u0026ndash;260.\u003c/li\u003e\n\u003cli\u003eMei Z, Wang Q, Zhang Y, Liu P, Ge M, Du P, et al .Risk factors for recurrence after anal fistula surgery: A meta- analysis. International journal of surgery. 2019; 69:153-64.\u003c/li\u003e\n\u003cli\u003eTyler KM, Aarons CB, Sentovich SM. Successful sphincter-sparing surgery for all anal fistulae. Dis Colon Rectum 2007; 50:1535\u0026ndash;1539.\u003c/li\u003e\n\u003cli\u003eSirikurnpiboon S, Awapittaya B, Jivapaisarnpong P. Ligation of intersphincteric fistula track and its modification: results from treatment of complex fistula. World J Gastrointest Surg 2013; 5:123\u0026ndash;128.\u003c/li\u003e\n\u003cli\u003eG\u0026ouml;ttgens KW, Janssen PT, Heemskerk J, Van Dielen FM, Konsten LM, Lettinga T, et al. Long-term outcome of low perianal fistulae treated by fistulotomy: a multicenter study. Int J Colorectal Dis 2015; 30:213\u0026ndash;219.\u003c/li\u003e\n\u003cli\u003evan Tets WF, Kuijpers HC. Continence disorders after anal fistulotomy. Dis Colon Rectum 1994; 37:1194\u0026ndash;1197.\u003c/li\u003e\n\u003cli\u003eCavanaugh M, Hyman N, Osler T. Fecal incontinence severity index after fistulotomy. Dis Colon Rectum 2002; 45:349\u0026ndash;353.\u003c/li\u003e\n\u003cli\u003eAbou-Zeid AA, Halim SA, Elghamrini Y. The use of re-routing operation in the treatment of high arching transsphincteric and suprasphincteric anal fistula: an observational study. Egypt J Surg. 2021;40:180-5.\u003c/li\u003e\n\u003cli\u003eOmar W, Alqasaby A, Abdelnaby M, Youssef M, Shalaby M, Abdel-Razik MA, et al. Drainage Seton Versus External Anal Sphincter-Sparing Seton After Re-routing of the Fistula Track in the Treatment of Complex Anal Fistula: A Randomized Controlled Trial. Diseases of the Colon \u0026amp; Rectum. 2019;62(8):980-7.\u003c/li\u003e\n\u003cli\u003eOuf TIA, Abdel-Wanees WA-A, Abd Elsamia YM, Abdelrazek AM. Comparative study between staged re-routing and rectal advancement flap with curettage of fistula track in treatment of horse shoe perianal fistula. Ain Shams Med J. 2020;71:689-99.\u003c/li\u003e\n\u003cli\u003eMaqsood SCR, Rasikh A. Re-routing of high/recurrent anal fistula without seton. Pak Armed Forces Med J. 2012;62:510-13.\u003c/li\u003e\n\u003cli\u003eIbrahim M, Yasser M, Salem A. Retrospective evaluation of outcome of re-routing technique in management of horseshoe perianal fistula, single institution experience. Med J Cairo Univ. 2021;89:505-11.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Re-routing, Tract, Treatment, High Anal Fistula","lastPublishedDoi":"10.21203/rs.3.rs-5738577/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5738577/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e High anal fistulae require more complicated treatment than low anal fistulae. Because of their complexity, this study aimed to assess the re-routing role in the high anal fistulae treatment, as well as to assess recurrence and incontinence, and determine whether re-routing of the tract is a good option for treating high anal fistulae.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e It is a prospective interventional study that was conducted on 83 patients with high perianal fistula, ranging in age from 18 to 72 years old, of both genders. All cases were assigned to history taking, laboratory investigations, clinical examination (general examination and local examination), and magnetic resonance imaging [MRI] for objective delineation of the fistulous tractand its attribution with the anal sphincters.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e· After a minimum follow-up period of 9 months, 5 cases (6.02%) experienced recurrence. Mild incontinence was reported in 4 patients (4.8%), while 4 patients (4.8%) developed infection. Additionally, tractgangrene was observed in 2 patients (2.41%).\u003c/p\u003e\n\u003cp\u003e· In multivariate regression, suprasphincteric fistulae, and infection were independent predictors for recurrence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe re-routing procedure is a feasible and safe surgical option for managing high transsphincteric perianal fistulae. It is associated with low postoperative complication rates, including short-term recurrence. It combines the advantages of fistulotomy and sphincter-preserving fistula surgery. However, further studies involving a large number of suprasphincteric fistula cases are needed to evaluate the efficacy of the re-routing technique in treating such fistulae.\u003c/p\u003e","manuscriptTitle":"Re-routing of the tract in the treatment of high anal fistula: A single-center experience ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-10 08:33:24","doi":"10.21203/rs.3.rs-5738577/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-06-06T17:12:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-16T20:11:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100786454345506198216129938904175842856","date":"2025-04-07T18:41:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-06T21:29:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54539394630810789807144069350301748890","date":"2025-04-06T17:36:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-05T18:26:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-26T14:02:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"Techniques in Coloproctology","date":"2025-03-24T15:47:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"26c58377-1bce-4885-9053-4854d6b955e6","owner":[],"postedDate":"April 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-28T16:06:01+00:00","versionOfRecord":{"articleIdentity":"rs-5738577","link":"https://doi.org/10.1007/s10151-025-03179-3","journal":{"identity":"techniques-in-coloproctology","isVorOnly":false,"title":"Techniques in Coloproctology"},"publishedOn":"2025-07-24 15:57:45","publishedOnDateReadable":"July 24th, 2025"},"versionCreatedAt":"2025-04-10 08:33:24","video":"","vorDoi":"10.1007/s10151-025-03179-3","vorDoiUrl":"https://doi.org/10.1007/s10151-025-03179-3","workflowStages":[]},"version":"v1","identity":"rs-5738577","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5738577","identity":"rs-5738577","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}