Zhang XC, Ma HF, Zhou ZY, Zhang LN, Kong F, Wang YM, Song XB, Wang Y. Fistulotomy under general anesthesia in infants and toddlers: A retrospective cohort study on perioperative safety and long-term recurrence. World J Gastroenterol 2026; 32(35): 121507 [DOI: 10.3748/wjg.121507]
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Yue Wang, MD, PhD, Doctor, Department of Proctology, China-Japan Friendship Hospital, No. 2 Yinghuayuan East Street, Chaoyang District, Beijing 100029, China. wangyue@zryhyy.com.cn
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Zhang XC, Ma HF, Zhou ZY, Zhang LN, Kong F, Wang YM, Song XB, Wang Y. Fistulotomy under general anesthesia in infants and toddlers: A retrospective cohort study on perioperative safety and long-term recurrence. World J Gastroenterol 2026; 32(35): 121507 [DOI: 10.3748/wjg.121507]
Xue-Cheng Zhang, Huang-Fu Ma, Yan-Mei Wang, Xin-Bo Song, Yue Wang, Department of Proctology, China-Japan Friendship Hospital, Beijing 100029, China
Zhang-Yun Zhou, Department of Gastrointestinal Surgery, Anhui Zhongke Gengjiu Hospital, Hefei 230051, Anhui Province, China
Li-Na Zhang, Department of Traditional Chinese Medicine Proctology, Hohhot Traditional Chinese and Mongolian Medicine Hospital, Hohhot 010000, Inner Mongolia Autonomous Region, China
Fang Kong, College of Acupuncture and Massage, Shandong University of Traditional Chinese Medicine, Jinan 250355, Shandong Province, China
Co-first authors: Xue-Cheng Zhang and Huang-Fu Ma.
Co-corresponding authors: Xin-Bo Song and Yue Wang.
Author contributions: Zhang XC and Ma HF drafted the manuscript, they contributed equally to this work as co-first authors; Wang Y and Song XB participated in the study design and coordination, they contributed equally to this work as they are co-corresponding authors; Zhang LN and Zhou ZY handled follow-up and data/picture collection; Zhang XC and Wang Y performed data curation; Kong F conducted software and formal analysis; Zhang XC, Ma HF, Zhou ZY, Zhang LN, Kong F, Wang YM, Song XB, Wang Y read and approved the final version.
AI contribution statement: AI tools (specifically ChatGPT) were used solely for linguistic refinement and formatting assistance. No AI tool was involved in the generation of research data, interpretation of results, or formulation of conclusions. All AI-generated outputs were critically reviewed and revised by the authors. AI tools (ChatGPT) were used solely for linguistic refinement and formatting assistance in the “Answering Reviewers”.
Supported by Independent Research Project of China-Japan Friendship Hospital, No. 2024-ZF-31.
Institutional review board statement: The study was approved by the Ethics Committee of China-Japan Friendship Hospital (approval No. 2024-KY-387).
Informed consent statement: The study was approved by the Ethics Committee of China-Japan Friendship Hospital, which waived the requirement for written informed consent. Verbal informed consent was obtained from all participants via telephone prior to enrollment.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
STROBE statement: The authors have read the STROBE Statement—a checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-a checklist of items.
Data sharing statement: All data supporting this study are included within the article and/or its Supplementary material.
Corresponding author: Yue Wang, MD, PhD, Doctor, Department of Proctology, China-Japan Friendship Hospital, No. 2 Yinghuayuan East Street, Chaoyang District, Beijing 100029, China. wangyue@zryhyy.com.cn
Received: April 2, 2026 Revised: April 30, 2026 Accepted: May 20, 2026 Published online: September 21, 2026 Processing time: 140 Days and 21 Hours
Abstract
BACKGROUND
Fistulotomy is a common treatment for fistula-in-ano (FIA) in children. However, the perioperative safety and long-term effectiveness of fistulotomy under general anesthesia (GA) in infants and toddlers remains uncertain.
AIM
To investigate the clinical characteristics of toddlers and infants undergoing fistulotomy and evaluate the perioperative safety and long-term outcomes.
METHODS
This retrospective cohort study was conducted at the China-Japan Friendship Hospital and included hospitalized patients aged 3 ≤ years who were diagnosed with FIA and underwent fistulotomy between January 2018 and March 2024. The primary outcome was perianal abscess or FIA recurrence rate during follow-up in infants (12 months) and toddlers (aged 1-3 years) after fistulotomy, which was also assessed using cox regression to identify associated risk factors. Secondary outcomes included perioperative adverse events and Kelly score.
RESULTS
A total of 675 patients (540 infants and 135 toddlers) with a median age of 11 months were included. Infants had a significantly shorter disease course and fistula incidence at the 4:00 and 8:00 (P < 0.05) positions compared with toddlers. A single case of severe intraoperative respiratory distress was successfully managed during GA. Common postoperative adverse events included somnolence and fever. After an average follow-up period of 30 months, the overall recurrence rate was 1.5%, which was significantly higher in toddlers (3.7%) than in infants (0.9%). Univariate and multivariate Cox regression identified toddlers and specific fistula locations (L5 and L9) as independent risk factors for recurrence in children under 3 years of age.
CONCLUSION
Fistula patterns and recurrence showed age-related differences. Fistulotomy under GA appears to be a safe and effective option for infants/toddlers with FIA, with low recurrence and a negligible impact on fecal continence.
Core Tip: Infants and toddlers differ in fistula location patterns and surgical outcomes, likely reflecting the distinct developmental pathological processes that evolve in early childhood. Our study reveals fistulotomy under general anesthesia appears to be a safe and effective option for infants/toddlers with fistula-in-ano, with low recurrence rate and a negligible impact on fecal continence. Given this favorable safety record, the potential risks of general anesthesia should be balanced against the benefits of definitive treatment, and necessary surgical intervention should not be postponed because of anesthesia concerns.
Citation: Zhang XC, Ma HF, Zhou ZY, Zhang LN, Kong F, Wang YM, Song XB, Wang Y. Fistulotomy under general anesthesia in infants and toddlers: A retrospective cohort study on perioperative safety and long-term recurrence. World J Gastroenterol 2026; 32(35): 121507
Fistula-in-ano (FIA), or anal fistula, is a chronic inflammatory tract that connects the anorectum to the external environment and typically arises following the rupture or surgical drainage of a perianal abscess (PA)[1,2]. Although its precise etiology remains unclear, it is primarily attributed to congenital anal gland anomalies, hormonal influences, and local trauma. In contrast to adults, FIA or PA in pediatric patients is widely thought to have a congenital rather than acquired etiology[3,4]. Consequently, the therapeutic strategies for pediatric FIA differ from those for adult FIA. Despite this recognized therapeutic distinction, studies characterizing pediatric FIA are scarce compared to those on adults. In particular, only a few studies have focused on FIA in children older than 12 months[5,6], and data on the characteristics and outcomes of FIA in toddlers (defined as 1-3 years of age) are even more limited[7].
Moreover, the optimal management of FIA in children remains controversial with no clinical guidelines[1,4,8,9]. Practice varies widely and often depends on the personal experiences and judgments of doctors and parents[10]. Treatments range from conservative measures (such as baths, antibiotic therapy, puncture or incision and drainage) to definitive surgical interventions, mainly including fistulotomy, fistulectomy, and seton placement[11,12]. A previous meta-analysis indicated that primary surgical intervention provides superior outcomes in terms of recurrence of pediatric FIA compared to initial conservative management or drainage alone[13]. Among the surgical approaches, fistulotomy is considered the most commonly performed procedure because of its relatively short recovery time and low morbidity[1,4,6,14,15].
However, some argue that pediatric FIA/PA is a self-limiting disorder, with a recent study suggesting comparable recurrence rates between surgical and conservative treatments, thereby fistulotomy or fistulectomy should be avoided[2,16]. Studies on fistulotomy in children are limited by small sample sizes, short follow-up durations, and widely variable recurrence rates, ranging from 0% to > 23.4%[15,17-20]. These factors fuel the ongoing uncertainty about its place in treatment and the optimal management strategy. Furthermore, concerns persist regarding the risk of fistulotomy under general anesthesia (GA) in very young children and the potential long-term impact of anal continence[1,21], despite literature suggesting that such complications are rare and often transient[4]. This situation contributes to significant decision-making dilemmas for clinicians and parents of this vulnerable population.
Here, we present a retrospective cohort study of 675 infants and toddlers with FIA who underwent fistulotomy under GA. This study was designed to investigate the clinical characteristics of this population and to evaluate the perioperative safety, long-term recurrence, and impact on anal function after fistulotomy.
MATERIALS AND METHODS
Patients
Patients who met the inclusion criteria at the China-Japan Friendship Hospital between January 2018 and March 2024 were included in this study. The study data were obtained from the electronic medical record system and telephone follow-ups. The inclusion criteria were as follows: (1) Age ≤ 3 years; and (2) meeting the diagnostic criteria of the International Classification of Diseases (ICD) for FIA (K60.301), low or subcutaneous FIA, and fistulotomy under GA during hospitalization. The diagnosis of FIA was based on medical history and physical examination, supplemented by anorectal ultrasonography when indicated. The exclusion criteria were as follows: (1) Presence of serious comorbid conditions, including diseases of vital organs, severe primary diseases (e.g., immune defects, neutropenia, malignancy, or hematopoietic system disorders), or inflammatory bowel disease (IBD); and (2) refusal by legal guardians to provide informed consent for the epidemiological survey and postoperative follow-up. The study was approved by the Medical Ethics Committee of China-Japan Friendship Hospital(Approval No. 2024-ZF-31) and registered in the Chinese Clinical Trial Registry. The study followed the Strengthening the Reporting of Cohort, Cross-Sectional, and Case-Control Studies in Surgery (STROCSS) reporting guideline.
Treatment strategy
The night before fistulotomy, patients usually received an enema. All fistulotomy procedures were performed by senior specialized colorectal surgeons with > 15 years of surgical experience. All procedures were performed under GA using a Datex-Ohmeda anesthesia workstation (GE Healthcare). No premedication was administered. After anesthesia induction by sevoflurane inhalation (up to 8% in 100% oxygen) via a face mask, intravenous access was established. Following induction, esketamine 0.2-0.5 mg/kg was administered as an intravenous bolus, with additional doses titrated based on the estimated surgical duration and the number of fistula tracts. Anesthesia was maintained with sevoflurane at 1-1.3 minimum alveolar concentration in an oxygen/air mixture. When necessary, remifentanil was infused for intraoperative analgesia, and propofol was administered for sedation. All patients were monitored with American Society of Anesthesiologists standard monitoring, including electrocardiography, noninvasive blood pressure, pulse oximetry, capnography (end-tidal CO2), and temperature. After GA, patients were placed in the lithotomy position, and the perineum was disinfected and covered with an aseptic sheet. A special pediatric probe was inserted through the external opening and traveled along the fistula carefully to identify the internal opening, before passing through the internal opening. If the probe could not be inserted via the external opening, an external fistulous opening was incised with a surgical blade before probe insertion to identify and penetrate the internal opening. Guided by the probe, the skin between the external and internal openings was cut to fully expose the fistula tract. Finally, the fistula tract wall was thoroughly inspected. If any area of suspected infected tissue was identified, it was carefully ablated using electrocautery. When necessary, the incision was extended to ensure adequate drainage. The surgical wound was filled with a sterile dressing and covered with sterile gauze. Schematic diagrams of the surgical procedure are shown and in Supplementary Figure 1. An ibuprofen suspension was used for postoperative analgesia in patients aged > 6 months.
Wound dressing and gauze were removed after the first bowel movement or on the first postoperative day. Cotton balls containing iodophor disinfectant were used to disinfect the wounds. A standard postoperative treatment protocol was recommended for parents of children to follow after fistulotomy; it included keeping the perianal area exposed, clean, and dry, making dressing changes, asking the children to take sitz baths or use a wet compress, and applying an ointment. Regular cleaning of the wound was also strongly recommended, either by the outpatient clinic or using a cotton swab at home at least once a day until the wound healed. Directed at maintaining formed stools, nutritional and pharmaceutical interventions, including montmorillonite powder and probiotics, were implemented for infants with loose or watery diarrhea. For persistent diarrhea, the possibility of lactose intolerance or specific allergies was evaluated, and targeted therapy was initiated to prevent reinfection resulting from prolonged symptoms. A weekly outpatient visit was recommended for wound assessment, during which the skin was reopened if premature healing was observed.
Follow-up
Follow-ups were conducted via telephone interviews supplemented with outpatient records. The primary endpoint was the recurrence of PA or FIA. PA recurrence was defined as development of PA at the same location after wound healing during fistulotomy. FIA was defined as the presence of a hole with or without pus drainage at the site of the anus at the same location after wound healing following fistulotomy and persisting for > 3 weeks[22]. The secondary endpoints were perioperative safety and anal functional outcomes, which were assessed using the Kelly score. Perioperative safety was defined as the determination of adverse events during the operation and 48 h after the operation. Information was obtained from patients' electronic medical records and through telephone interviews conducted by an independent investigator.
Statistical analysis
Statistical analysis was performed using IBM SPSS Statistics 26.0 and R 4.6.0. Patients were divided into two groups based on their age at fistulotomy (i.e., specifically infant and toddler groups). Descriptive statistics were computed and reported, including the mean and standard deviation (SD) or median (interquartile range) for continuous variables, and frequency (proportion of each group) for categorical variables. Continuous variables were compared using the nonparametric Mann-Whitney U-test. Fisher’s exact and χ2 tests were then used to compare the categorical data. Univariate and multivariate Cox analysis were performed for assessing the significance of the variables for recurrence. All reported P-values are two-sided, and P-values < 0.05 were used to denote statistical significance.Materials and Methods section affirming that the statistical review of the study was performed by a biomedical statistician.
RESULTS
Between January 2018 and March 2024, 803 pediatric patients underwent fistulectomy during hospitalization at the China-Japan Friendship Hospital. After excluding 80 patients who did not meet the study criteria and 48 who were unavailable for follow-up (34 with incorrect contacts and 12 who declined consent), 675 patients were included in the final analysis. After an average follow-up period of 30 months (16, 57), 10 (1.5%) of the children that underwent the procedure experienced a recurrence of PA or FIA. The details are shown in Figure 1, and a example of postoperative wound recovery is shown in Supplementary Figure 1.
The demographic, clinical, and operative characteristics of the patients and their postoperative outcomes are shown in Table 1. All patients included in this study were male, with 540 (80.0%) infants and 135 (20.0%) toddlers. A single case of severe intraoperative respiratory distress was successfully managed with full patient recovery and no sequelae. The median duration of surgery was 16.00 (10.00, 20.00) min, and common postoperative adverse events included somnolence (13.7%) and fever (19.1%). Although the interval between the operation and the first anal fistula was significantly longer in toddlers than in infants (4 months vs 8 months, P < 0.05), no significant differences were observed between the two groups in operative time, length of hospital stay, or time to complete wound healing. The recurrence rate was significantly higher in toddlers (5/135, 3.7%) than infants (5/540, 0.9%). Preoperative laboratory indexes of the patients are shown in Supplementary Figure 1.
Table 1 Baseline characteristics and surgical outcomes of infants and toddlers with fistula-in-ano, n (%)/median interquartile range.
Characteristic
Overall (n = 675)
Infants (n = 540)
Toddlers (n = 135)
P value
Male
675 (100)
540 (100)
135 (100)
Mean age at the operation (month)
11.00 (7.00, 12.00)
9.00 (7.00, 12.00)
24.00 (21.00, 36.00)
< 0.001
Interval between the operation and the first anal fistula (month)
The characteristics of the fistulas among the patients are shown in Table 2. Most patients (n = 363, 53.9%) had only a single fistula, while the 9:00 (n = 342, 50.67%) and 3:00 (n = 321, 47.56%) positions were the most common direction of fistula. A significant difference in fistula incidence at the 4:00 and 8:00 positions was observed between infants and toddlers (P < 0.05). However, no significant intergroup differences were found in the number of fistulas or their distribution at other positions.
Table 2 Characteristics of fistula of infants and toddlers, n (%).
Upon follow-up, the Kelly scores of the vast majority of children (665, 98.5%) were 5 or 6. Leakage, muscle strength, and the sensation of defecation were affected after surgery in very few children; the details are presented in Table 3.
Table 3 Long-term functional outcomes of patients after according to Kelly’s score, n (%).
Several factors were found to be associated with PA or FIA recurrence (Table 4) after univariate and multivariate Cox regression analysis, including the age at operation (toddlers vs infants) and direction of fistulas (L5 and L9). Compared to infants, toddlers had a significantly higher risk of recurrence, with a hazard ratio of 4.81 (95% confidence interval: 1.330-17.375; P = 0.017). Moreover, multiple fistulas was associated with increased recurrence on univariate but not multivariate analysis.
Table 4 Univariate and multivariate Cox regression analysis of risk factors for fistula-in-ano or perianal abscess recurrence.
To the best of our knowledge, this is the first large-sample cohort study to focus on the long-term outcomes of fistulotomy under GA, specifically in infants and toddlers with FIA. Our findings indicate that fistulotomy performed under GA in this population is associated with a favorable safety profile. Long-term outcomes showed a low recurrence rate at the primary location (1.5%) after fistulotomy and that the operation rarely led to compromised anal function.
The safety of GA in infants and toddlers is a critical consideration, particularly given the known higher risk of perioperative respiratory events in children under 2 years of age[23,24]. Surgical treatment of FIA remains empiric[5]; however, parental apprehension regarding GA frequently results in prolonged conservative management, with a study reporting an average preoperative waiting time of 26.6 months in children with FIA[21,25]. Reassuringly, evidence from a multicenter randomized controlled trial indicated that GA exposure for less than 1 hour did not adversely affect long-term neurodevelopment[26]. While additional evidence is required for broader inferences regarding long-term neurodevelopmental safety, our results further support the perioperative safety of GA in infants. Major anesthesia-related complications were infrequent among the 675 patients, with only one case of severe intraoperative respiratory distress. Most adverse events were transient (e.g., fever and lethargy), likely attributable in part to the short operative duration (mean, 16 minutes). Given this observed safety record, the potential risks of GA should be balanced against the benefits of definitive treatment, and necessary surgical intervention should not be postponed solely because of anesthesia concerns.
Consistent with previous studies, our cohort exhibited a marked male preponderance, with the 3:00 and 9:00 positions being the most common fistula sites[27-29]. This extreme sex disparity is characteristic of pediatric FIA and may be attributed to androgen-driven differences in anal gland development during embryogenesis, which predispose male infants and toddlers to deep crypts and subsequent fistulization[11]. A novel finding of our study is the distinct differences observed between infants and toddlers. Toddlers presented with a longer preoperative disease duration and a higher incidence of fistulas at the 4:00 and 8:00 positions, and, most importantly, a significantly higher postoperative recurrence rate.
These differences may suggest an evolving FIA pathophysiology in early childhood. According to the prevailing congenital theory, androgen-influenced developmental defects can lead to abnormally deep anal crypts. These crypts trap stool and bacteria, creating a nidus for inflammation that may progress from an abscess to FIA[5,30-32]. This concept was supported by the temporal coincidence between peak androgen levels around 1 year of age and the peak incidence of perianal disease[33]. The congenital nature of early-onset FIA has been corroborated by anatomical studies. Based on the histology of specimens from adults, stillborn infants, and neonates, Parks[34] observed that abscesses and FIAs in the very young presented with a circumferential distribution, lacking a predilection for the anterior and posterior commissures typical of acquired FIAs in older populations. As children transition into toddlerhood, this congenital predisposition is likely modulated by acquired factors[11]. Longer disease duration and increased incidence at the 4:00 and 8:00 positions, along with factors such as altered stool patterns and increased physical activity, may influence disease progression[21]. Furthermore, studies on pathological examination revealed distinct muscle compositions between the two age groups, with infant fistula tracts consisting predominantly of smooth muscle and minimal striated muscle, whereas toddler tracts contained both smooth and striated muscle with a relatively higher proportion of striated muscle[35]. These factors can promote tract fibrosis, complexity, and other features associated with surgical challenges[1]. Although the number of fistulas did not differ between the groups, the potential for such structural evolution might have been underestimated in our study, as detailed tract characteristics, such as height and branching, were not systematically evaluated due to the lack of ultrasonography. Therefore, the disease may be more difficult to treat in toddlers, resulting in poor surgical outcomes. Furthermore, the notion that earlier intervention may be advantageous is supported by a separate study that reported that infants under 6 months of age derived greater benefits from surgical management[17].
The observed FIA/PA recurrence rate of 1.5% in our cohort was lower than that reported in previous pediatric studies. A systematic review conducted in 2011 reported a pooled recurrence rate of 5.8% (16/274), specifically for fistulotomy[6]. Furthermore, two other systematic reviews reported overall recurrence rates of approximately 7% and 10.6% following operative management of FIA[4,13] using a variety of surgical approaches, including incision and drainage, seton placement, and fistulectomy. Several factors may have contributed to these low recurrence rates. First, we defined recurrence strictly as reappearance at the original surgical site, whereas other studies have often used a broader definition encompassing any new recurrence at a different location[17]. Consequently, our recurrence figures are not directly comparable to those reported in studies using a broader definition. In addition, the follow-up periods varied considerably across previous studies, ranging from 3 months to 3 years[4,6,13], possibly contributing to the disparity in reported recurrence rates. Second, the fistulotomy was augmented by electrocautery ablation of the tract wall and incision extension, when needed. This step aimed to destroy the infected tissue of partial fistula tract, thereby approximating the effect of fistulectomy in which tract wall should be excised[36]. This may explain why our recurrence rate closely resembles the lower rates reported for fistulectomy (1.1%, 1/88)[6], rather than higher rates for standard fistulotomy. Thirdly, all procedures were performed by senior surgeons, which may have contributed to the low recurrence rates observed. Importantly, our study did not include a non-surgical control group or a comparison arm receiving treatment with alternative surgical techniques, such as seton placement or fistulectomy. Therefore, our conclusions regarding the safety and effectiveness of fistulotomy remain largely descriptive. The absence of a non-surgical control group limits our ability to draw definitive conclusions regarding the relative benefit of surgical intervention, and our findings may inherently favor the surgical approach.
Furthermore, our analysis identified several factors associated with the risk of recurrence, including toddlers (compared to infants), multiple fistula tracts, and fistulas located at the 5:00 or 9:00 positions. In adult populations, recurrence is often linked to complex anatomy, such as high transsphincteric or horseshoe extensions, prior surgical history, or specific interventions[37]. The association between multiple tracts and higher recurrence rates was consistent across the age groups. However, young age and specific anatomical locations are independent risk factors that are unique to the pediatric population. The identification of the 5:00 and 9:00 positions as risk locations extends our observation that the fistula distribution differs between infants (predominantly 3:00/9:00) and toddlers (higher incidence at 4:00/8:00). We hypothesize that this pattern might be related to the vulnerability of certain anal crypts, combined with evolving mechanical forces on the perineum as a child begins to walk and sit. This clinical observation raises the possibility that developmental processes in patients with FIA during early childhood may differ fundamentally from the acquired anatomical complexities typical in adults, although these interpretations remain speculative owing to a lack of direct histological or imaging confirmation in this study. Understanding these age-related pathogenic differences and risk factors for recurrence may be essential for developing tailored treatment strategies[25]. A systematic review and meta-analysis on adults revealed a statistically significant protective effect for antibiotic treatment after incision and drainage. While a meta-analysis on adults suggested a protective effect of postoperative antibiotics against recurrence[38], our study and another pediatric cohort (n = 108) found no such significant association[39]. This discrepancy may stem from the differing etiologies, as pediatric FIA is primarily congenital, potentially limiting the role of antibiotics after source control. Overall, in infants and toddlers, complete surgical excision may be more critical for preventing recurrence than adjuvant antibiotic therapy.
In our study, anal function was assessed using the Kelly score, which is the most commonly employed method for assessing fecal incontinence in contemporary practice[40,41]. In terms of scores, 98.5% of the patients achieved a high score (5 or 6) at the long-time follow-up, corresponding to good continence[42]. Nonetheless, as with any perianal surgery, the potential impact on continence must be thoroughly discussed with parents during preoperative counseling to ensure fully informed consent.
This study has several limitations. First, this retrospective, single-center study included only hospitalized patients who underwent surgery, which limits the generalizability of our findings to other clinical settings. Second, our study focused specifically on patients with FIA and excluded those with PA. This distinction was made because FIA represents the formation of a chronic inflammatory tract and the two conditions are often managed and studied separately. We also excluded patients with specific causes, such as inflammatory bowel disease or neutropenia, because their distinct pathophysiology and outcomes after surgery may confound the analysis of idiopathic FIA. These exclusion criteria may limit the applicability of our findings to these groups. Third, detailed, systematic imaging-based classification of fistula tracts, such as length, height or branch patterns, was not available for analysis in a substantial proportion of patients owing to the inconsistent use of preoperative ultrasonography. Moreover, our study lacked histological examination and standardized intraoperative structural assessments. Fourth, the exclusively male composition of our cohort, while consistent with the known sex disparity of pediatric FIA, limits the applicability of our results to female patients. Finally, the low number of recurrence events, while clinically favorable, limited the statistical power of the multivariate Cox regression analysis and likely contributed to overfitting, as reflected by wide confidence intervals for several hazard ratios (e.g., toddlers vs infants; L5 and L9 fistula locations). The multivariate estimates should therefore be interpreted cautiously.
CONCLUSION
This study demonstrated that infants and toddlers differ in fistula location patterns and surgical outcomes. Findings from our cohort suggest that fistulotomy under GA appears to be a safe and effective option for FIA in infants and toddlers, with a low recurrence rate and minimal impact on fecal continence. However, these findings warrant validation through further large-scale prospective studies. The risks and benefits of fistulotomy should be considered on a case-by-case basis, and necessary surgical intervention should not be delayed due to concerns related to age and GA.
ACKNOWLEDGEMENTS
We want to thank all the patients who participated in this study.
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