The Garg phenomenon in supralevator anal fistulas: Avoiding overtreatment of the additional supralevator rectal opening to preserve continence

We read with great interest Karlović et al.'s article detailing the ASGIIFT technique 1, which rightly emphasizes intersphincteric management and sphincter preservation. Building upon this vital discourse, we highlight a specific anatomical scenario where avoiding overtreatment is equally paramount: the supralevator fistula-in-ano presenting with an additional supralevator rectal opening (ASRO). Supralevator fistulas are formidable challenges requiring precise preoperative magnetic resonance imaging mapping 2. Historically, addressing an ASRO—a secondary high rectal opening situated above the primary internal opening at the dentate line—carried catastrophic risks to continence mechanisms and pelvic floor integrity. Prior to recent research, no definitive guidelines directed ASRO management 2. The first comparative study addressing this was conducted by Garg et al. in 2021 3. The ASRO was managed via three intraoperative strategies: laying open into the rectum, mucosal cauterization or leaving it entirely untreated. Remarkably, fistulas healed successfully regardless of the ASRO strategy. The clinical observation—once the primary internal opening at the dentate line is adequately managed, then leaving the ASRO completely untreated does not compromise ultimate healing—is aptly termed the ‘Garg phenomenon’ 4. This phenomenon aligns seamlessly with classic cryptoglandular theory 5. Once the primary infected anal gland at the dentate line is eradicated, halting the influx of sepsis, the secondary high supralevator tract loses its infective drive and heals spontaneously 5. In modern sphincter-preserving surgery, the ‘Garg phenomenon’ represents a vital paradigm shift. By understanding that the ASRO heals spontaneously once the primary opening is addressed, colorectal surgeons can confidently avoid perilous high rectal dissections. Applying the ‘Garg phenomenon’ prevents unnecessary surgical morbidity and secures long-term continence. Nicola Clemente: Conceptualization; writing – review and editing; project administration; software; methodology; validation; supervision. Abdallah Hmitti: Conceptualization; writing – review and editing; investigation; validation; methodology; software; supervision; data curation. James C. W. Khaw: Conceptualization; writing – original draft; writing – review and editing; project administration; formal analysis; methodology; data curation; investigation. The authors have nothing to report. The authors have nothing to report. None reported. No patient or patient data involved. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.