Patients and methodology Treatment of Complex Anal Fistula Momcilo Stosic, Igor Stojanovic Deparment of Surgery, General Hospital Vranje Introduction Results Anal fistula is abnormal tract which connects the anal canal with perianal skin including the anal sphincter 1. Parks classification is based upon the position of the fistula penetrating the sphincter 2. The fistula may be either simple or complex 3. A complex fistula is determined by one of the following conditions: its track crosses >30% to 50% of the external sphincter, an anterior fistula in females, multiple track, a recurrent fistula and the one in patients with pre-existing incontinence, local irradiation or Crohn's disease 4,5. Due to the involvement of the anal sphincter, the complex fistula treatment runs a high risk of continence impairment 6. The aim is to present the way we solved our series of complex fistulas. All patients were operated under on general anesthesia. An internal opening had not been identified preoperatively in two patients: the one with the tract to the left thigh and the one with HS. The reason was the presence of granulation in the tract. The operation began by injecting hydrogen in the outer opening. The next step was probing. In the cases with fibrosis in the tract, we did curettage all the way to the inner opening. Then we observed a possible arborization. Next, a fistulectomy and an excision of secundary tract were done. In one case, a rubber seton was placed. Postoperative incontinence was not registered. Conclusion Patients and methodology In complex fistulas, it is not always possible to determine the internal opening. It is always necessary to open a secondary tract. After a certain period of time, we had one recidive. We present here the cases of 6 patient with complex fistulas operated in the regional hospital in the last two years (2012-2013) by one surgeon (Figure 1-6). The diagnosis is done by probing, methylene-blue injection and fistulography. EUS and MRI are not available in our department. The cases included two horseshoe fistulas, one transphincteric with the second tract in the scrotum, one anterior in a female, one with the route in left thigh and one combined with hidradenitis suppurativa glutei (HS). Referencis 1. Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. British Journal of Surgery 1976;63(1):1-12. 2. Gupta PJ, Gupta SN, Heda PS. Which treatment for anal fistula? Cut or cover, plug or paste, loop or lift. Acta Chir Iugosl. 2012;59(2):15-20. 3. Ajay Sud, Arif Khan. Benign anal conditions: haemorrhoids, fissures, perianal abscess, fistula-in-ano and pilonidal sinus. Surgery (Oxford) 2014;32(8):421–6. 4. Kodner IJ, Mazor A, Shemesh EI, Fry RD, Fleshman JW, Birnbaum EH. Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas. Surgery 1993;114(4):682-690. 5. AM El-Tawil. Management of fistula-in-ano: An introduction. World J Gastroenterol 2011; 17(28): 3271. 6 Kumar N, Agarwal Y, Chawla AS, Thukral BB. Significance of MR imaging in setting the ball path of surgical management in perianal fistulae. Apollo medicine 2014;11:179-183. Contact momcilostosic@gmail.com www.momcilostosic.wix.com/hirurskiugao Figure 1-6.