{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T13:59:26Z","timestamp":1787061566663,"version":"build-2736575974"},"reference-count":10,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,4,30]],"date-time":"2026-04-30T00:00:00Z","timestamp":1777507200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Surg."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Complex anal fistulas remain a surgical challenge due to their intricate anatomy, high recurrence rates, and potential for sphincter injury. We report a rare case of complex anal fistula with multiple external openings extending from the gluteal region to the thigh root, successfully managed by combined incision with drainage tube placement.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case presentation<\/jats:title>\n                    <jats:p>A 57-year-old man presented with recurrent purulent discharge from the perianal region and left lower limb for three months following debridement of a lower extremity soft tissue infection. Physical examination revealed multiple unhealed wounds on the left buttock, thigh root, and lower limb with purulent exudation. A cord-like sinus tract was palpable in the left perianal region extending into the anal canal and communicating with the buttock wound. Pelvic contrast-enhanced MRI demonstrated multiple enhancing sinus tracts within the left gluteal subcutaneous tissue and gluteus maximus muscle, extending superomedially to the posterior anal aspect and inferolaterally along the muscle surface to the dorsal thigh root. Fistulography confirmed communication between the left buttock fistula and the rectum, with contrast entering the rectal lumen approximately 2.0\u2005cm from the anal verge. Colonoscopy revealed two NICE type 2 polyps in the descending and sigmoid colon (3\u2005mm\u2009\u00d7\u20093\u2005mm and 6\u2005mm\u2009\u00d7\u20097\u2005mm), which were removed by endoscopic mucosal resection; pathology confirmed tubular adenomas. The patient underwent fistulotomy with drainage tube placement for the high trans-sphincteric tract extending to the supralevator space, along with partial sinus tract excision and drainage tube insertion. Intraoperative blood loss was approximately 10\u2005mL. The postoperative course was uneventful, and at six-month follow-up, the wounds had completely healed with no signs of recurrence and normal anal sphincter function.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This rare case of complex anal fistula with multiple external openings and deep extension to the thigh root highlights the critical role of multimodal imaging (MRI and fistulography) in preoperative planning. Combined incision, drainage, and drainage tube placement achieved successful outcomes with preserved sphincter function.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fsurg.2026.1823865","type":"journal-article","created":{"date-parts":[[2026,4,30]],"date-time":"2026-04-30T05:33:15Z","timestamp":1777527195000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Ascending complex anal fistula secondary to lower extremity soft tissue infection: a case report"],"prefix":"10.3389","volume":"13","author":[{"given":"Jiyuan","family":"Zhang","sequence":"first","affiliation":[{"name":"Department of General Surgery, The Second Hospital of Hebei Medical University","place":["Shijiazhuang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiaopeng","family":"Ma","sequence":"additional","affiliation":[{"name":"Department of General Surgery, The Second Hospital of Hebei Medical University","place":["Shijiazhuang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Liangchen","family":"Li","sequence":"additional","affiliation":[{"name":"Department of General Surgery, The Second Hospital of Hebei Medical University","place":["Shijiazhuang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiaoning","family":"Qin","sequence":"additional","affiliation":[{"name":"Department of General Surgery, The Second Hospital of Hebei Medical University","place":["Shijiazhuang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leiran","family":"Feng","sequence":"additional","affiliation":[{"name":"Department of General Surgery, The Second Hospital of Hebei Medical University","place":["Shijiazhuang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Guiying","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of General Surgery, The Second Hospital of Hebei Medical University","place":["Shijiazhuang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,4,30]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"127","DOI":"10.1007\/s10151-019-02144-1","article-title":"Evaluation and management of perianal abscess and anal fistula: SICCR position statement","volume":"24","author":"Amato","year":"2020","journal-title":"Tech Coloproctol"},{"key":"B2","doi-asserted-by":"publisher","first-page":"917","DOI":"10.1080\/17474124.2018.1500175","article-title":"Fistula-associated anal carcinoma in Crohn\u2019s disease","volume":"12","author":"Yamamoto","year":"2018","journal-title":"Expert Rev Gastroenterol Hepatol"},{"key":"B3","doi-asserted-by":"publisher","first-page":"443","DOI":"10.1016\/S0033-8389(02)00122-7","article-title":"Imaging anal fistula","volume":"41","author":"Bartram","year":"2003","journal-title":"Radiol Clin North Am"},{"key":"B4","doi-asserted-by":"publisher","first-page":"51","DOI":"10.1016\/j.suc.2025.08.012","article-title":"Anal Abscess and Fistula","volume":"106","author":"Gandhi","year":"2026","journal-title":"Surg Clin North Am"},{"key":"B5","doi-asserted-by":"publisher","first-page":"827","DOI":"10.1007\/s10151-023-02845-8","article-title":"Efficacy of different surgical treatments for management of anal fistula: a network meta-analysis","volume":"27","author":"Bhat","year":"2023","journal-title":"Tech Coloproctol"},{"key":"B6","doi-asserted-by":"publisher","first-page":"153","DOI":"10.1016\/j.ijsu.2019.08.003","article-title":"Risk factors for recurrence after anal fistula surgery: a meta-analysis","volume":"69","author":"Mei","year":"2019","journal-title":"Int J Surg"},{"key":"B7","doi-asserted-by":"publisher","first-page":"e11882","DOI":"10.7759\/cureus.11882","article-title":"Comparison of the efficacy of the various treatment modalities in the management of perianal Crohn\u2019s fistula: a review","volume":"12","author":"Feroz","year":"2020","journal-title":"Cureus"},{"key":"B8","doi-asserted-by":"publisher","first-page":"595","DOI":"10.1007\/s00384-014-2104-7","article-title":"Complex anal fistula remains a challenge for colorectal surgeon","volume":"30","author":"Cadeddu","year":"2015","journal-title":"Int J Colorectal Dis"},{"key":"B9","doi-asserted-by":"crossref","first-page":"937","DOI":"10.15537\/1658-3175.6025","article-title":"Anal fistula. Past and present","volume":"35","author":"Zubaidi","year":"2014","journal-title":"Saudi Med J"},{"key":"B10","doi-asserted-by":"publisher","first-page":"e948682","DOI":"10.12659\/AJCR.948682","article-title":"Management of complex anal fistula in recurrent perianal abscess: a case report","volume":"26","author":"Zhang","year":"2025","journal-title":"Am J Case Rep"}],"container-title":["Frontiers in Surgery"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fsurg.2026.1823865\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,30]],"date-time":"2026-04-30T05:33:16Z","timestamp":1777527196000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fsurg.2026.1823865\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,30]]},"references-count":10,"alternative-id":["10.3389\/fsurg.2026.1823865"],"URL":"https:\/\/doi.org\/10.3389\/fsurg.2026.1823865","relation":{},"ISSN":["2296-875X"],"issn-type":[{"value":"2296-875X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,30]]},"article-number":"1823865"}}