We read with great interest the article on the TROPIS procedure by Reyez Diaz et al.1 They demonstrated the efficacy of TROPIS in exclusively high (>30% external anal sphincter involved) fistulas. They reported a healing rate of 73.9% after one year in 23 patients. We innovated TROPIS in 2017,2 and so far we have performed this procedure in 1101 complex anal fistulas (all were MRI-proven high fistulas) with a long-term cure rate of >84% over a median follow-up of 66 months.3,4 A recent meta-analysis has highlighted a weighted healing rate of 89% after TROPIS.5 Interestingly, another meta-analysis highlighted that amongst all sphincter-sparing procedures, TROPIS has the highest cure rate in complex fistula-in-ano.6
We would like to share innovative applications of TROPIS that have helped simplify the treatment of this dreaded morbid disease, namely the Garg phenomenon, and a few practical points on enhancing the success rate of TROPIS.
Not uncommonly, along with a primary internal opening at the dentate line, supralevator, and translevator fistulas are associated with an additional internal opening in the mid-rectum: the additional supralevator rectal opening (ASRO).7,8 ASRO was a major therapeutic challenge, and there were no guidelines in the literature as to how ASRO should be managed. The first comprehensive paper on the management of ASRO, the Garg phenomenon, was published by us in 2021.9
As per the Garg phenomenon, “The fistula and the ASRO heal well even if nothing is done to the ASRO. The proper management of the primary opening at the dentate line holds the key to fistula healing, and ASRO is perhaps not very responsible for the persistence of the fistula.”9 In a controlled study in supralevator fistulas managed by TROPIS, ASRO was managed in 3 ways: the ASRO was laid open in continuity with the intra-anal wound, the ASRO and the surrounding mucosa were only cauterized, and nothing was done to ASRO.9 Among 138 fistulas with supralevator extensions, 23 had ASRO as all supralevator extensions did not open into the rectum.9 After a median follow-up of 29 months (range 2–62 months), the healing in all 3 groups was not statistically different.9
Regarding postoperative care, in TROPIS, unlike other procedures where the internal primary opening is closed, the aim is to heal the internal opening by secondary intention because, in the presence of infection, the healing is better with secondary intention. Therefore, once the intersphincteric tract is deroofed (laid-open) through the transanal route in TROPIS, it is important to ensure the healing of the resulting intra-anal wound by secondary intention. This can be done by marsupialization of the wound edges and by doing per-rectal examination to prevent sticking of wound edges periodically (every 2nd–3rd day) in the postoperative period till the wound heals completely (6–10 weeks). Regular Kegel exercises have even been shown to prevent minor, insignificant incontinence after partial incision of the internal sphincter (TROPIS).10
Financial source of supportNil.
The author has no conflicts of interest to declare.
Nil.
