Hi. Thanks for your query. Noted the history and understood the concern. Fistula in ano is very typical in its cause, types viz high anal or low anal and hence its treatment and outcome. The fistula means both the ends are connected to different area with lining of mucus membrane and/ or skin as in anal fistula case. Even a small part the remains can cause it to recur after surgery. Recurrence after 4 years can be due to formation of a new one or has some pre- existing condition like Crohns or Tuberculosis. Iwould advice you the following in such a condition: Get a Contrast Fistulogram or MRI done to know whether this is high anal or low anal. This will decide what kind of surgery would be required. Alternative is Kshar Sutra procedure and it helps for cure.