Annals of Coloproctology

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Review

Anorectal benign disease

Artificial intelligence in anal fistula: mapping evidence to IDEAL stages: Vipul D Yagnik, Prema Ram Choudhary, Pankaj Garg; Ann Coloproctol. 2026;42(3):264-272. Published online June 25, 2026; DOI: https://doi.org/10.3393/ac.2025.01494.0213

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Artificial intelligence (AI) is increasingly applied in colorectal and anorectal surgery, particularly for complex conditions such as anal fistula (AF). Conventional diagnostic and therapeutic approaches remain limited by intricate anatomy, high recurrence risk, and the need to preserve continence. This narrative review, evaluates the role of AI in AF and related anorectal disorders, with evidence mapped to the IDEAL (idea, development, exploration, assessment, and long-term follow-up) framework (stages 1–4, with stage 2 subdivided into 2a and 2b). Relevant literature was identified through targeted searches of PubMed, Embase, and Scopus. Studies investigating AI applications in AF or related anorectal conditions, including imaging, surgical planning, predictive modeling, and functional assessment, were included. Evidence was categorized according to IDEAL stages, ranging from proof-of-concept to long-term quality assurance. AI demonstrates potential across 4 key domains: (1) preoperative imaging (stages 1–2b); (2) intraoperative planning and assistance (stages 1–2a); (3) predictive modeling (stages 2a–2b); and (4) broader anorectal applications, including anorectal manometry and the EndoFLIP (endoluminal functional lumen imaging probe) procedure (stages 1–2b). Feasibility studies report high diagnostic performance, particularly for magnetic resonance imaging and computed tomography–based deep learning models; however, these findings are constrained by small sample sizes, limited external validation, and challenges related to workflow integration. Overall, AI has the potential to enhance diagnostic accuracy, surgical planning, and functional assessment in AF and related disorders. However, most studies remain within early IDEAL stages (1–2b), highlighting the need for multicenter validation, cost-effectiveness analyses, and robust ethical frameworks before widespread clinical implementation.

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Revisiting the ‘surgeon in the loop’: From deskilling to human–AI collaboration
Vipul D. Yagnik, Pankaj Garg
Colorectal Disease.2026;[Epub] CrossRef
Clinical utility beyond detection rates: Interpreting artificial intelligence in FIT‐positive colonoscopy
Divyesh A. Patel
Colorectal Disease.2026;[Epub] CrossRef

Technical Note

Anorectal benign disease

Botulinum injection technique to reduce spasms in refractory anal fissures and after anal fistula or hemorrhoid surgery: Pankaj Garg, Vipul D. Yagnik, Kaushik Bhattacharya; Ann Coloproctol. 2024;40(6):610-612. Published online December 2, 2024; DOI: https://doi.org/10.3393/ac.2023.00696.0099

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FACTORS AFFECTING THE RESULTS OF TREATMENT FOR CHRONIC ANAL FISSURES
L. Hrytsak, A. Aksan, L. Bilansky
Neonatology, Surgery and Perinatal Medicine.2026; 16(1(59)): 121. CrossRef
Ischemic component in the pathogenesis of chronic anal fissure: microcirculatory remodeling and fibrosis
L. Hrytsak, M. Aksan, L. Bilyansky
Reports of Vinnytsia National Medical University.2026; 30(1): 62. CrossRef
Current Treatment of Chronic Anal Fissures in Adults: Recommendations and Actual Surgical Practice
L. I. Hrytsak, L. S. Bilanskyi, M. V. Aksan
The Ukrainian Journal of Clinical Surgery.2026; 93(2): 78. CrossRef

Review

Anorectal benign disease

Recent advances in the diagnosis and treatment of complex anal fistula: Pankaj Garg, Kaushik Bhattacharya, Vipul D. Yagnik, G. Mahak; Ann Coloproctol. 2024;40(4):321-335. Published online August 30, 2024; DOI: https://doi.org/10.3393/ac.2024.00325.0046

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21 Web of Science
28 Citations

Abstract PDF

Anal fistula can be a challenging condition to manage, with complex fistulas presenting even greater difficulties. The primary concerns in treating this condition are a risk of damage to the anal sphincters, which can compromise fecal continence, and refractoriness to treatment, as evidenced by a high recurrence rate. Furthermore, the treatment of complex anal fistula involves several additional challenges. Satisfactory solutions to many of these obstacles remain elusive, and no consensus has been established regarding the available treatment options. In summary, complex anal fistula has no established gold-standard treatment, and the quest for effective therapies continues. This review discusses and highlights groundbreaking advances in the management of complex anal fistula over the past decade.

Citations

Citations to this article as recorded by

Long-term outcomes of video-assisted anal fistula treatment
Sirindhra Suepiantham, Giovanni Santoro, Michael Chadwick, Ramya Kalaiselvan, Ajai Samad, Rajasundaram Rajaganeshan
Surgical Endoscopy.2026; 40(4): 3368. CrossRef
Ligation of the intersphincteric fistula tract vs conventional surgery for anal fistula in Chinese patients
Xue Li, Cong-Cong Zhi, Xiao-Long Wang, Li-Hua Zheng, Yi-Cheng Cheng
World Journal of Gastrointestinal Surgery.2026;[Epub] CrossRef
Comparison of the proposed new classification of anal fistulas with the Garg classification
Pankaj Garg, Nicola Clemente, Kaushik Bhattacharya, Sattyadeep Garg
Annals of Coloproctology.2026; 42(1): 145. CrossRef
Clinical Patterns and Treatment Outcomes of Selected Benign Anorectal Conditions in a Tertiary Care Hospital in Vijayapura, India: A Retrospective Observational Study
Nishikant N Gujar, Mohammed Sohail Malkhed, Krishna Vemuri
Cureus.2026;[Epub] CrossRef
A randomized controlled study on the efficacy and function of internal sphincter lowering combined with external sphincter denudation and virtual hanging drainage in the treatment of complex anal fistula
Ling Wang, Xindan Zhang, Fuheng Liu, Ji Jin, Xiu Wang, Gang Zhao
Frontiers in Surgery.2026;[Epub] CrossRef
Video-assisted anal fistula treatment for complex anorectal fistula: meta-analysis
Wenjing Wang, Yu Du, Yiwei Wang, Jingming Zhao
BJS Open.2026;[Epub] CrossRef
Sphincter-Sparing Procedures Need to Be Effective in High Anal Fistulas
Pankaj Garg, Vipul D. Yagnik, Kaushik Bhattacharya
Diseases of the Colon & Rectum.2026; 69(6): 1788. CrossRef
Risk factors for fecal incontinence after surgery for cryptoglandular anal fistula: Protocol of a meta-analytic study
Cheng Tang, Zubing Mei, Xing-Xiong An
PLOS One.2026; 21(6): e0351563. CrossRef
The role of the SIRPG-AS1/miR-3692-5p/STAT1 axis in recurrent pediatric anal fistula
Zhaomin Wang, Shengbing Tu
Pediatrics & Neonatology.2026;[Epub] CrossRef
Sphincter-induced dynamic obstruction in a synthetic intersphincteric anal fistula model: a proof-of-concept fluid–structure interaction study
Qiuxiang Yu
Frontiers in Medicine.2026;[Epub] CrossRef
Treating complex posterior horseshoe anal fistula with ksharsutra ligation (medicated seton) for interconnected fistulous tracts: A case study
Samata Semaskar, Piyush Pardhekar, Megha Tidke
Multidisciplinary Science Journal.2026; 8(12): 2026778. CrossRef
Comparative effectiveness of sphincter-sparing and non-sphincter-sparing procedures for complex anal fistulas: a systematic review and network meta-analysis of postoperative incontinence, pain, and quality of life
Mohamad Sadek Zoghbi, Lama Hamade, Dima Itani, Yomna El Zibaoui, Moustafa Moussally, Emre Gorgun
Surgery.2026; : 110469. CrossRef
Modified anal fistula clip: A safe and effective alternative to incision and thread hanging for anal fistula
Ying Han, Xiao-Li Fang, Kun Tang, Ran Tang, Xian-Shui Mei, Run Zhang, Li Chen, Jian-Min Wang, Ming Li
World Journal of Gastrointestinal Surgery.2026;[Epub] CrossRef
Impact of Diagram-assisted MRI Fistulogram on Surgical Outcomes in Fistula-in-ano: A Retrospective Comparative Study
Sumit Kumar, Ram Kumar Bharosh, Aakansha Agarwal, Mohammad Hashim, Saransh Puri, Chinmay M. Biradar
Apollo Medicine.2026;[Epub] CrossRef
Understanding the anatomical basis of anorectal fistulas and their surgical management: exploring different types for enhanced precision and safety
Asim M. Almughamsi, Yasir Hassan Elhassan
Surgery Today.2025; 55(4): 457. CrossRef
Mucosal advancement flap versus ligation of the inter-sphincteric fistula tract for management of trans-sphincteric perianal fistulas in the elderly: a retrospective study
Tamer A. A. M. Habeeb, Massimo Chiaretti, Igor A. Kryvoruchko, Antonio Pesce, Aristotelis Kechagias, Abd Al-Kareem Elias, Abdelmonem A. M. Adam, Mohamed A. Gadallah, Saad Mohamed Ali Ahmed, Ahmed Khyrallh, Mohammed H. Alsayed, Esmail Tharwat Kamel Awad, M
International Journal of Colorectal Disease.2025;[Epub] CrossRef
Evaluating the predictive superiority of Garg's classification for surgical decision-making in perianal fistula management
Naresh Lodhi, Dileep Thakur, Amrendra Verma, Uday Somashekar, Deepti Bala Sharma, Dhananjaya Sharma
Tropical Doctor.2025; 55(2): 124. CrossRef
Tuberculosis in anal fistula: incidence, clinical insights, and diagnostic challenges
Tariq Akhtar Khan, Mohammad Ali, Krishna Pada Saha, M. Nashir Uddin, M. Lutful Kabir Khan, Nunjirul Muhsenin, Nazmun Nahar, Sawantee Joarder, M. Kuddus Ali Khan
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Validation of a novel imaging-guided and anatomy-based classification system for anorectal fistulas: a retrospective clinical evaluation study
Antonio Brillantino, Francesca Iacobellis, Luigi Marano, Adolfo Renzi, Pasquale Talento, Luigi Brusciano, Claudio Gambardella, Umberto Favetta, Michele Schiano Di Visconte, Luigi Monaco, Maurizio Grillo, Mauro Natale Maglio, Fabrizio Foroni, Alessio Palum
Annals of Coloproctology.2025; 41(3): 207. CrossRef
Application of micro-dynamic negative pressure wound therapy in treating cavity wounds after complex anal fistula surgery
Ruyun Cai, Zhonghua Hong
Asian Journal of Surgery.2025; 48(12): 7854. CrossRef
Hotspots and trends of perianal fistula of Crohn’s disease: A bibliometric analysis
Lei Liang, Lan Li, Dexin Wang, Xiubi Zhang, Xiaohe Zhang, Gang Tian, Chaochi Yue, Weiliang Du
Medicine.2025; 104(32): e43854. CrossRef
IL-6 and TNF variants as potential determinants of perianal disease in Crohn's patients: a pilot study
Jessica Cusato, Gian Paolo Caviglia, Alfredo Santovito, Gabriele Ascani, Alessandra Manca, Marta Vernero, Angelo Armandi, Eleonora Dileo, Miriam Antonucci, Maria Alessandra Pavan, Antonio D'Avolio, Davide Giuseppe Ribaldone
Cytokine.2025; 196: 157064. CrossRef
Mucosal Advancement Flap Versus Ligation of the Intersphincteric Fistula Tract for Transsphincteric Fistula-in-Ano: A Comparative Study in a Tertiary Care Hospital
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Nasreen Hanifa, Hemantha Kumar Parlapothula, Rekha Chandrodaya
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Levator ani involvement in perianal fistulas: MRI-based insights into complex anatomy
Sezer Nil Yılmazer Zorlu, Diğdem Kuru Öz, Ayşe Erden
Abdominal Radiology.2025; 51(7): 3366. CrossRef
From the Editor: Uniting expertise, a new era of global collaboration in coloproctology
In Ja Park
Annals of Coloproctology.2024; 40(4): 285. CrossRef
Surgeon oriented reporting template for magnetic resonance imaging and endoanal ultrasound of anal fistulas enhances surgical decision-making
Si-Ze Wu
World Journal of Radiology.2024; 16(12): 712. CrossRef
Abbreviations Anonymous: A Coloproctologist’s Guide to Sanity
Kaushik Bhattacharya
Indian Journal of Colo-Rectal Surgery.2024; 7(1): 1. CrossRef

Letter to the Editor

Local plus oral antibiotics and strict avoidance of constipation is effective and helps prevents surgery in most cases of anal fissure: Pankaj Garg, Vipul D. Yagnik, Kaushik Bhattacharya; Ann Coloproctol. 2023;39(2):188-189. Published online November 29, 2022; DOI: https://doi.org/10.3393/ac.2022.00731.0104

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Uncovering the Link Between Pre-Surgery Constipation and the Success of Surgery for Chronic Anal Fissure
İlyas Kudaş, Fatih Başak, Aylin Acar, Hüsna Tosun, Yahya Kemal Calışkan, Olgun Erdem, Tolga Canbak
Journal of Coloproctology.2025; 45(02): e1. CrossRef

Original Article

Anorectal benign disease

Garg scoring system to predict long-term healing in cryptoglandular anal fistulas: a prospective validation study: Sushil Dawka, Vipul D. Yagnik, Baljit Kaur, Geetha R. Menon, Pankaj Garg; Ann Coloproctol. 2024;40(5):490-497. Published online October 11, 2022; DOI: https://doi.org/10.3393/ac.2022.00346.0049

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9 Citations

Abstract PDF

Purpose
Complex anal fistulas can recur after clinical healing, even after a long interval which leads to significant anxiety. Also, ascertaining the efficacy of any new treatment procedure becomes difficult and takes several years. We prospectively analyzed the validity of Garg scoring system (GSS) to predict long-term fistula healing.
Methods
In patients operated for cryptoglandular anal fistulas, magnetic resonance imaging was performed preoperatively and at 3 months postoperatively to assess fistula healing. Scores as per the GSS were calculated for each patient at 3 months postoperatively and correlated with long-term healing to check the accuracy of the scoring system.
Results
Fifty-seven patients were enrolled, but 50 were finally included (7 were excluded). These 50 patients (age, 41.2±12.4 years; 46 men) were followed up for 12 to 20 months (median, 17 months). Forty-seven patients (94.0%) had complex fistulas, 28 (56.0%) had recurrent fistulas, 48 (96.0%) had multiple tracts, 20 (40.0%) had horseshoe tracts, 15 (32.0%) had associated abscesses, 5 (10.0%) were suprasphincteric, and 8 (16.0%) were supralevator fistulas. The GSS could accurately predict long-term healing (high positive predictive value, 31 of 31 [100%]) but was not very accurate in predicting nonhealing (negative predictive value, 15 of 19 [78.9%]). The sensitivity in predicting healing was 31 of 35 (88.6%).
Conclusion
GSS accurately predicts long-term fistula with a high positive predictive value (100%) but is less accurate in predicting nonhealing. This scoring system can help allay anxiety in patients and facilitate the early validation of innovative procedures for anal fistulas.

Citations

Citations to this article as recorded by

A transperineal ultrasound-based scoring system (J-TPUSS) for predicting healing after cryptoglandular fistula surgery in resource-limited settings
Dileep Singh Thakur, Rashmi Mishra, Amrendra Verma, Uday Somashekar, Deepti Bala Sharma, Dhananjaya Sharma
Tropical Doctor.2026; 56(3): 496. CrossRef
Ultrasound-based scoring to predict long-term healing in anal fistula: A practical alternative or complementary to the MRI-based Garg scoring system?
Pankaj Garg, Kaushik Bhattacharya, Vipul Yagnik
Tropical Doctor.2026;[Epub] CrossRef
Special Considerations in Anal Fistula Management
Vaishnavi Kavirayani, Swadha Das Guru
Clinics in Colon and Rectal Surgery.2026;[Epub] CrossRef
External validation of the modified Parks classification of cryptoglandular anal fistula to predict failure of healing: the protocol for a retrospective analysis
Alireza Teymouri, Amir Keshvari, Faezeh Khorasanizadeh, Alireza Kazemeini, Behnam Behboudi, Mohammad Sadegh Fazeli, Mohammad Reza Keramati, Ali Ashjaei, Seyed Mohsen Ahmadi Tafti, Amirhosein Naseri
International Journal of Surgery Protocols.2025; 29(3): 118. CrossRef
Recent Advances in the Understanding and Management of Anal Fistula from India
Vipul D. Yagnik, Sandeep Kumar, Anshul Thakur, Kaushik Bhattacharya, Sushil Dawka, Pankaj Garg
Indian Journal of Surgery.2024; 86(6): 1105. CrossRef
Rectovaginal Fistulas Not Involving the Rectovaginal Septum Should Be Treated Like Anal Fistulas: A New Concept and Proposal for a Reclassification of Rectovaginal Fistulas
Pankaj Garg, Laxmikant Ladukar, Vipul Yagnik, Kaushik Bhattacharya, Gurleen Kaur
Clinical and Experimental Gastroenterology.2024; Volume 17: 97. CrossRef
Recent advances in the diagnosis and treatment of complex anal fistula
Pankaj Garg, Kaushik Bhattacharya, Vipul D. Yagnik, G. Mahak
Annals of Coloproctology.2024; 40(4): 321. CrossRef
Predictors of outcome in cryptoglandular anal fistula according to magnetic resonance imaging: A systematic review
Alireza Teymouri, Amir Keshvari, Ali Ashjaei, Seyed Mohsen Ahmadi Tafti, Faeze Salahshour, Faezeh Khorasanizadeh, Amirhosein Naseri
Health Science Reports.2023;[Epub] CrossRef
Pankaj Garg: A Community Doctor to a Master Innovator to a Global Icon
David N. Armstrong, Iwona Sudoł-Szopińska, Vincent de Parades, Francesco Litta, Manuel Limbert, Khaw C. W. James
Global Journal of Medical, Pharmaceutical, and Biomedical Update.2023; 18: 16. CrossRef

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