Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2019 Aug;23(8):729-741.
doi: 10.1007/s10151-019-02051-5. Epub 2019 Jul 31.

Contemporary surgical practice in the management of anal fistula: results from an international survey

C Ratto  1   2 , U Grossi  3   4 , F Litta  1 , G L Di Tanna  5 , A Parello  1 , V De Simone  1 , P Tozer  6   7 , D DE Zimmerman  8 , Y Maeda  9
Affiliations

Contemporary surgical practice in the management of anal fistula: results from an international survey

C Ratto et al. Tech Coloproctol. 2019 Aug.

Abstract

Background: Management of anal fistula (AF) remains challenging with many controversies. The purpose of this study was to explore current surgical practice in the management of AF with a focus on technical variations among surgeons.

Methods: An online survey was conducted by inviting all surgeons and physicians on the membership directory of European Society of Coloproctology and American Society of Colon and Rectal Surgeons. An invitation was extended to others via social media. The survey had 74 questions exploring diagnostic and surgical techniques.

Results: In March 2018, 3572 physicians on membership directory were invited to take part in the study 510 of whom (14%) responded to the survey. Of these respondents, 492 (96%) were surgeons. Respondents were mostly colorectal surgeons (84%) at consultant level (84%), age ≥ 40 years (64%), practicing in academic (53%) or teaching (30%) hospitals, from the USA (36%) and Europe (34%). About 80% considered fistulotomy as the gold standard treatment for simple fistulas. Endorectal advancement flap was performed using partial- (42%) or full-thickness (44%) flaps. Up to 38% of surgeons performed ligation of the intersphincteric fistula tract (LIFT) sometimes with technical variations. Geographic and demographic differences were found in both the diagnostic and therapeutic approaches to AF. Declared rates of recurrence and fecal incontinence with these techniques were variable and did not correlate with surgeons' experience. Only 1-4% of surgeons were confident in performing the most novel sphincter-preserving techniques in patients with Crohn's disease.

Conclusions: Profound technical variations exist in surgical management of AF, making it difficult to reproduce and compare treatment outcomes among different centers.

Keywords: Anal fistula; Incontinence; LIFT; Recurrence; Survey; VAAFT.

PubMed Disclaimer

Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Usefulness ratings of diagnostic modalities in patients with anal fistula (a cryptoglandular; b Crohn’s disease related). MRI magnetic resonance imaging, EAUS endoanal ultrasound, CT computed tomography
Fig. 2
Fig. 2
Surgeons’ attitudes towards incision and drainage (I&D) of perianal abscess. NB: multi-answer questions—percentage of respondents who selected each answer option (e.g., 100% would represent that all these question’s respondents chose that option)
Fig. 3
Fig. 3
Number of cases per year according to each surgical technique. ERAF endorectal advancement flap, LIFT ligation of the intersphincteric fistula tract, VAAFT video-assisted anal fistula treatment, FiLaC fistula laser closure, OTSC over-the-scope clip
Fig. 4
Fig. 4
Recommended surgical techniques according to anal fistula type. Bars indicate 95% confidence intervals. ERAF endorectal advancement flap, VAAFT video-assisted anal fistula treatment, FiLaC fistula laser closure, OTSC over-the-scope clip
See this image and copyright information in PMC

References

    1. Parks AG. Pathogenesis and treatment of fistula-in-ano. Br Med J. 1961;1(5224):463–469. doi: 10.1136/bmj.1.5224.463. - DOI - PMC - PubMed
    1. Zanotti C, Martinez-Puente C, Pascual I, Pascual M, Herreros D, Garcia-Olmo D. An assessment of the incidence of fistula-in-ano in four countries of the European Union. Int J Colorectal Dis. 2007;22(12):1459–1462. doi: 10.1007/s00384-007-0334-7. - DOI - PubMed
    1. Owen HA, Buchanan GN, Schizas A, Cohen R, Williams AB. Quality of life with anal fistula. Ann R Coll Surg Engl. 2016;98(5):334–338. doi: 10.1308/rcsann.2016.0136. - DOI - PMC - PubMed
    1. Kotze PG, Shen B, Lightner A, Yamamoto T, Spinelli A, Ghosh S, et al. Modern management of perianal fistulas in Crohn’s disease: future directions. Gut. 2018;67(6):1181–1194. doi: 10.1136/gutjnl-2017-314918. - DOI - PubMed
    1. Lee MJ, Heywood N, Adegbola S, Tozer P, Sahnan K, Fearnhead NS, et al. Systematic review of surgical interventions for Crohn’s anal fistula. BJS Open. 2017;1(3):55–66. doi: 10.1002/bjs5.13. - DOI - PMC - PubMed