Anal fistulas: do classification systems predict surgical outcomes?

Abstract

Background: Anal fistulas remain challenging in colorectal surgery, with recurrence and postoperative incontinence common despite advances in treatment. Multiple classification systems exist, but their predictive value for surgical and functional outcomes is unclear.

Aims: The aim of this study was to compare Parks, American Society of Colon and Rectal Surgeons (ASCRS), and St. James's University Hospital (SJUH) MRI-based classifications in predicting surgical outcomes, including continence preservation.

Methods: Retrospective analysis of 89 patients undergoing definitive surgical treatment for anorectal fistulas at a single referral center (2012-2019). Exclusions included rectovaginal fistulas, Crohn's disease, or prior pelvic radiotherapy. Fistulas were classified using Parks, ASCRS, and, when available, SJUH (n=49). Outcomes included the number of procedures, type of initial procedure, fistula closure, and closure without continence deterioration. Continence was assessed using the Cleveland Clinic Jorge-Wexner score.

Results: Most fistulas were transsphincteric (Parks Type 2, 62%) and complex (ASCRS, 65%). Overall, 86.5% achieved fistula closure, and 73% achieved closure without continence deterioration. Parks and ASCRS were significantly associated with fistula closure with continence preservation (p=0.008 and 0.007, respectively) and type of initial procedure. Parks remained significant when considering closure alone (p=0.005), while ASCRS showed a borderline association (p=0.051). SJUH classification was associated only with procedure selection.

Conclusions: Parks and ASCRS classifications were associated with fistula closure with continence preservation and type of initial procedure. Considering closure alone, only Parks remained significant. SJUH was limited to procedure selection. Overall, Parks and ASCRS guide surgical planning and prediction of functional outcomes, with Parks slightly more sensitive.

Central message: Parks and ASCRS classifications are strongly associated with initial procedure choice and functional outcomes, including fistula closure with continence preservation. SJUH classification predicts only procedure selection. Parks appears slightly more sensitive, highlighting its value for surgical planning and anticipating postoperative function.

Perspectives: Accurate classification of anal fistula is essential for guiding surgical strategies and counseling patient effectively. The Parks and ASCRS classification systems help predict which fistulas are likely to close successfully while preserving continence. Understanding the strengths and limitations of each system allows clinicians to select appropriate procedures, set realistic expectations, and facilitate shared decisionmaking. This approach ultimately improves outcomes in the management of complex anal fistulas.