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Evaluation and management of perianal abscess and anal fistula: SICCR position statement

Abstract

Perianal sepsis is a common condition ranging from acute abscess to chronic anal fistula. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. Surgery is the main treatment and several procedures have been developed, but the risks of recurrence and of impairment of continence still seem to be an unresolved issue. This statement reviews the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

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References

  1. 1.

    Eisenhammer S (1954) Advances in anorectal surgery with special reference to ambulatory treatment. S Afr Med J 28:264

  2. 2.

    Goligher JC, Ellis M, Pissidis AG (1967) A critique of anal glandular infection in the aetiology and treatment of idiopathic anorectal abscesses and fistulas. Br J Surg 54:977–983

  3. 3.

    Lunniss PJ, Phillips RKS (1994) Surgical assessment of acute anorectal sepsis is a better predictor of fistula than microbiological analysis. Br J Surg 81:368–369

  4. 4.

    Parks AG (1961) Pathogenesis and treatment of fistula-in-ano. Br Med J 18:463–469

  5. 5.

    Williams JG, Farrands PA, Williams AB et al (2007) The treatment of anal fistula: ACPGBI position statement. Colorectal Dis 9:18–50

  6. 6.

    Lillius HG (1968) An investigation on human foetal anal ducts and intramuscular glands: a clinical study of 150 patients. Acta Chir Scan 383:7–88

  7. 7.

    Abeysuriya V, Salgado LS, Samarasekera DN (2010) The distribution of the anal glands and the variable regional occurrence of fistula-in-ano: is there a relationship? Tech Coloproctol 14:317–321

  8. 8.

    Marks CG, Ritchie JK, Lockhart-Mummery HE (1981) Anal fistulas in Crohn’s disease. Br J Surg 68:525–527

  9. 9.

    Culp CE (1983) Chronic hidradenitis of the anal canal: a surgical skin disease. Dis Colon Rectum 26:669–676

  10. 10.

    Shukla HS, Gupta SC, Singh G, Singh PA (1988) Tubercular fistula in ano. Br J Surg 75:38–39

  11. 11.

    Eisenhammer S (1956) The internal anal sphincter and the anorectal abscess. Surg Gynecol Obstet 103:501–506

  12. 12.

    Parks AG, Gordon PH, Hardcastle JD (1976) A classification of fistula-in-ano. Br J Surg 63:1–12

  13. 13.

    Sneider EB, Maykel JA (2013) Anal abscess and fistula. Gastroenterol Clin N Am 42:773–784

  14. 14.

    Zanotti C, Martinez-Puente C, Pascual I, Pascual M, Herreros D, Garcia-Olmo D (2007) An assessment of the incidence of fistula-in-ano in four countries of the European union. Int J Color Dis 22:1459–1462

  15. 15.

    Sainio P (1984) Fistula-in-ano in a defined population. Incidence and epidemiological aspects. Ann Chir Gynaecol 73:219–224

  16. 16.

    Hamalainen KP, Sainio AP (1998) Incidence of fistulas after drainage of acute anorectal abscesses. Dis Colon Rectum 41:1357–1361

  17. 17.

    Fazio VW (1987) Complex anal fistulae. Gastroenterol Clin North Am 16:93–114

  18. 18.

    Luniss PJ, Sheffield JP, Talbot IC, Thomson JP, Phillips RK (1995) Persistence of idiopathic anal fistula may be related to epithlialization. Br J Surg 82:32–33

  19. 19.

    van Koperen PJ, Ten Kate FJ, Bemelman WA, Slors JF (2010) Histological identification of epithelium in perianal fistulae: a prospective study. Colorectal Dis 12(9):891–895

  20. 20.

    Mitalas LE, van Onkelen RS, Monkhorst K, Zimmerman DD, Gosselink MP, Schouten WR (2012) Identification of epithelization in high transsphincteric fistulas. Tech Coloproctol 16(2):113–117

  21. 21.

    Göttgens KW, Smeets RR, Stassen LP, Beets G, Breukink SO (2015) Systematic review and meta-analysis of surgical interventions for high cryptoglandular perianal fistula. Int J Colorectal Dis 30:583–593

  22. 22.

    Amato A, Bottini C, De Nardi P, Giamundo P, Lauretta A, Realis Luc A, Tegon G, Nicholls RJ (2015) Evaluation and management of perianal abscess and anal fistula: a consensus statement developed by the Italian society of colorectal surgery (SICCR). Tech Coloprctol 19:595–606

  23. 23.

    Guyatt G, Gutterman D, Baumann MH et al (2006) Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American college of chest physicians task force. Chest 129:174–181

  24. 24.

    Parks AG, Thompson JPS (1973) Intersphinteric abscess. Br Med J 2:537–539

  25. 25.

    Goldberg SM, Gordon PH, Nivatvongs S (1980) Essential of anorectal surgery. JB Lippincott, Philadelphia, pp 100–127

  26. 26.

    Nelson J, Billingham R (2007) Pilonidal disease and hidradenitis suppurativa. In: Wollf BG, Fleshman JW, Beck DE, et al. (eds) The ASCRS textbook of colon and rectal surgery. Springer, New York, pp 228–235

  27. 27.

    Goodsall DH, Miles WE (1982) Anorectal fistula. Dis Colon Rectum 25:262–278

  28. 28.

    Cirocco WC, Reilly JC (1992) Challenging the predictive accuracy of Goodsall’s rule for anal fistulas. Dis Colon Rectum 35:537–542

  29. 29.

    Gunawardhana PA, Keen DI (2001) Comparison of hydrogen peroxide instillation with Goodsall’s rule for fistula-in-ano. Aust NZ J Surg 71:472–474

  30. 30.

    Law PJ, Talbot RW, Bartram CI, Northover JMA (1989) Anal endosonography in the evaluation of perianal sepsis and fistula in ano. Br J Surg 76:752–755

  31. 31.

    Spencer JA, Chapple K, Wilson D, Ward J, Windsor AC, Ambrose NS (1998) Outcome after surgery for perianal fistula: predictive value of MR imaging. Am J Roentgenol 171:403–406

  32. 32.

    Morris J, Spencer JA, Ambrose NS (2000) MR Imaging classification of perianal fistulas and its implications for patient management. Radiographics 20:623–635

  33. 33.

    Beets-Tan RG, Beets GL, van der Hoop AG et al (2001) Preoperative MR imaging of anal fistulas: does it really help the surgeon? Radiology 218:75–84

  34. 34.

    Gustafsson UM, Kahvecioglu B, Astrom G et al (2001) Endoanal ultrasound or magnetic resonance imaging for preoperative assessment of anal fistula: a comparative study. Colorectal Dis 3:189–197

  35. 35.

    Lengyel AJ, Hurst NG, Williams JG (2002) Pre-operative assessment of anal fistulas using endoanal ultrasound. Colorectal Dis 4:436–440

  36. 36.

    Kuijpers HC, Schulpen T (1985) Fistulography for fistula-in-ano: is it useful? Dis Colon Rectum 28:103–104

  37. 37.

    Weisman RI, Orsay CP, Pearl RK et al (1991) The role of fistulography in fistula-in-ano: report of 5 cases. Dis Colon Rectum 34:181–184

  38. 38.

    Buchanan GN, Halligan S, Bartram CI et al (2004) Clinical examination, endosonography, and MR imaging in preoperative assessment of fistula in ano: comparison with outcome-based reference standard. Radiology 233(3):674–681

  39. 39.

    Piloni V, Chiavarini M, Fabbroni L et al (2016) Practical MR imaging of anal fistula disease: how we do it. Int J Coll Res Int Med Pub Health 8(9):561–571

  40. 40.

    Cheong DMO, Nogueras JJ, Wexner SD, Jagelman DG (1993) Anal endosonography for recurrent fistulas: image enhancement with hydrogen peroxide. Dis Colon Rectum 36:1158–1160

  41. 41.

    Ratto C, Gentile E, Merico M et al (2000) How can the assessment of fistula-in-ano be improved? Dis Colon Rectum 43:1375–1382

  42. 42.

    West RL, Zimmerman DD, Dwarkasing S et al (2003) Prospective comparison of hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging of perianal fistulas. Dis Colon Rectum 46:1407–1415

  43. 43.

    Santoro GA, Ratto C, Di Falco G (2004) Three-dimensional reconstructions improve the accuracy of endoanal ultrasonography in the identification of internal openings of anal fistulas. Colorect Dis 6(suppl):214

  44. 44.

    Sun Y, Cui LG, Liu JB et al (2018) Utility of 360° real-time endoanal sonography for evaluation of perianal fistulas. J Ultrasound Med 37:93–98

  45. 45.

    Cho DY (1999) Endosonographic criteria for an internal opening of fistula in ano. Dis Colon Rectum 42:515–518

  46. 46.

    Stewart LK, McGee J, Wilson SR (2001) Transperineal and transvaginal sonography of perianal inflammatory disease. AJR Am J Roentgenol 177:627–632

  47. 47.

    Wedemeyer J, Kirchhofft T, Sellge G et al (2004) Transcutaneous perianal sonography: a sensitive method for the detection of perianal inflammatory lesions in Crohn’s disease. World J Gastroenterol 10:2859–2863

  48. 48.

    de Souza NM, Hall AS, Puni R et al (1996) High resolution magnetic resonance imaging of the anal sphincter using a dedicated endoanal coil. Comparison of magnetic resonance imaging with surgical findings. Dis Colon Rectum 39:926–934

  49. 49.

    deSouza NM, Gilderdale DJ (1998) Coutts GA (1998) MRI of fistula-in-ano: a comparison of endoanal coil with external phased array coil techniques. J Comp Assist Tomogr 22:357–363

  50. 50.

    Spencer JA, Ward J, Beckingham IJ, Adams C, Ambrose NS (1996) Dynamic contrast-enhanced MR imaging of perianal fistulas. Am J Roentgenol 167:735–741

  51. 51.

    Schafer O, Lohrmann C, Langer M (2003) (2003) Digital subtraction MR fistulography: new diagnostic tool for the detection of fistula in ano. AJR 181:1611–1613

  52. 52.

    Brook RH, Chassin MR, Fink A et al (1986) A method for the detailed assessment of the appropriateness of medical technologies. Int J Tech Ass Health Care 2:53–63

  53. 53.

    Siddiqui MR, Ashrafian H, Tozer P et al (2012) A diagnostic accuracy meta-analysis of endoanal ultrasound and MRI for perianal fistula assessment. Dis Colon Rectum 55(5):576–585

  54. 54.

    Ommer A, Herold A, Berg E et al (2017) German S3 guidelines: anal abscess and fistula (second revised version. Langenbecks Arch Surg. 402(2):191–201

  55. 55.

    Pescatori M, Ayabaca S, Caputo D (2004) Can anal manometry predict anal incontinence after fistulectomy in males? Colorectal Dis 6:97–102

  56. 56.

    Sainio P (1985) A manometric study of anorectal function after surgery for anal fistula, with special reference to incontinence. Acta Chir Scand 151:695–700

  57. 57.

    Pescatori M, Maria G, Anastasio G, Rinallo L (1989) Anal manometry improves the outcome of surgery for fistula-in-ano. Dis Colon Rectum 32:588–592

  58. 58.

    Luchtefeld MA (2001) Anorectal abscess and fistula-in-ano. Clin Colon Rectal Surg 14:221–231

  59. 59.

    Senéjoux A, Siproudhis L (2013) «B.A.-BA SANS EBM…» du traitement des abcès et des fistules anales: 10 questions basiques (… ou à se poser fréquemment) Dis Colon Rectum 7:205–208

  60. 60.

    Buyukasik Y, Ozcebe OI, Sayinalp N et al (1998) Perianal infections in patients with leukemia: importance of the course of neutrophil count. Dis Colon Rectum 41:81–85

  61. 61.

    Cohen JS, Paz IB, O’Donnell MR, Ellenhorn JD (1996) Treatment of perianal infection following bone marrow transplantation. Dis Colon Rectum 39:981–985

  62. 62.

    Wilson W, Taubert KA, Gewitz T et al (2007) Prevention of infective endocarditis. guidelines from the American heart association: a guideline from the American heart association rheumatic fever, endocarditis, and kawasaki disease committee, council on cardiovascular disease in the young, and the council on clinical cardiology, council on cardiovascular surgery and anesthesia, and the quality of care and outcomes research interdisciplinary working group. Circulation 16:1736–1754

  63. 63.

    Ghahramani L, Mohammad RM, Arasteh P, Vahid Hosseini S, Izadpanah A, Bananzadeh AM, Ahmadbegi M, Hooshanginejad Z (2017) Antibiotic therapy for prevention of fistula in-ano after incision and drainage of simple perianal abscess: a randomized single blind clinical trial. Surgery 5:1017–1025

  64. 64.

    Ramanujam PS, Prasad ML, Abcarian H, Tan AB (1984) Perianal abscess and fistulas. Dis Colon Rectum 27:593–597

  65. 65.

    Matthew JF (2005) Anal abscesses and fistulas. ANZ J Surg 75:64–72

  66. 66.

    Onaca N, Hirshberg A, Adar R (2001) Early reoperation for perirectal abscess: a preventable complication. Dis Colon Rec-tum 44:1469–1473

  67. 67.

    Held D, Khubchandani I, Sheets J, Stasik J, Rosen L, Riether R (1986) Management of anorectal horseshoe abscess and fistula. Dis Colon Rectum 29:793–797

  68. 68.

    Malik AI, Nelson RL, Tou S (2010) Incision and drainage of perianal abscess with or without treatment of anal fistula. Cochrane Database Syst Rev 7:CD006827.

  69. 69.

    Quah HM, Tang CL, Eu KW, Chan SY, Samuel M (2005) Meta-analysis of randomized clinical trials comparing drainage alone vs primary sphincter-cutting procedures for anorectal abscess-fistula. Int J Colorectal Dis 30:1–8

  70. 70.

    Tan KK, Liu X, Tsang CB, Koh DC (2012) Identification of the internal anal opening and seton placement improves the out-come of deep postanal space abcess. Colorectal Dis 15:598–601

  71. 71.

    Schouten WR, van Vroonhoven TJ (1991) Treatment of anorectal abscess with or without primary fistulectomy. results of a prospective randomized trial. Dis Colon Rectum 34:60–63

  72. 72.

    Cox SW, Senagore AJ, Luchtefeld MA, Mazier WP (1997) Outcome after incision and drainage with fistulotomy for ischiorectal abscess. Am Surg 63:686–689

  73. 73.

    Davies M, Harris D, Lohana P et al (2008) The surgical management of fistula-in-ano in a specialist colorectal unit. Int J Colorectal Dis 23:833–838

  74. 74.

    Ho KS, Tsang C, Seow-Choen F, Tang CL, Heah SM, Eu KW (2001) Prospective randomized trial comparing ayurvedic cutting seton and fistulotomy for low fistula-in-ano. Tech Coloproctol 5:137–141

  75. 75.

    Westerterp M, Volkers NA, Poolman RW, van Tets WF (2003) Anal fistulotomy between Scylla and Charybdis. Colorectal Dis 5:549–551

  76. 76.

    J Jordan, JV Roig, García-Armengol J, García -Granero E, Solana A, Lledo S, (2010) Risk factors for recurrence and incontinence after anal fistula surgery Colorectal Dis 12:254–260

  77. 77.

    Garcia-Aguilar J, Belmonte C, Wong WD, Goldberg SM, Madoff RD (1996) Anal fistula surgery. Factors associated with recurrence and incontinence. Dis Colon Rectum 39:723–729

  78. 78.

    Chang SC, Lin JK (2003) Change in anal continence after surgery for intersphincteral anal fistula: a functional and manometric study. Int J Colorectal Dis 18:111–115

  79. 79.

    Cavanaugh M, Hyman N, Osler T (2002) Fecal incontinence severity index after fistulotomy: a predictor of quality of life. Dis Colon Rectum 45:349–353

  80. 80.

    Buchanan GN, Williams AB, Bartram CI, Halligan S, Nicholls RJ, Cohen CR (2003) Potential clinical implications of direction of a trans-sphincteric anal fistula track. Br J Surg 90:1250–1255

  81. 81.

    Gupta PJ (2003) Radiosurgical fistulotomy; an alternative to conventional procedure in fistula in ano. Curr Surg 60:524–528

  82. 82.

    Gupta PJ (2003) Radio frequency ‘‘sutureless’’ fistulotomy- a new way of treating fistula in anus. World J Gastroenterol 9:1082–1085

  83. 83.

    Filingeri V, Gravante G, Baldessari E, Casciani CU (2004) Radiofrequency fistulectomy vs. diathermic fistulotomy for submucosal fistulas: a randomized trial. Eur Rev Med Pharmacol Sci 8:111–116

  84. 84.

    Jacob TJ, Perakath B, Keighley MR (2010) Surgical intervention for anorectal fistula. Cochrane Database Syst Rev 12:CD006319.

  85. 85.

    Ho YH, Tan M, Leong AF, Seow-Choen F (1998) Marsupialization of fistulotomy wounds improves healing: a randomized controlled trial. Br J Surg 85:105–107

  86. 86.

    Pescatori M, Ayabaca SM, Cafaro D, Iannello A, Magrini S (2006) Marsupialization of fistulotomy and fistulectomy wounds improves healing and decreases bleeding: a randomized controlled trial. Colorectal Dis 8:11–14

  87. 87.

    Lentner A, Wienert V (1996) Long-term, indwelling setons for low transsphincteric and intersphincteric anal fistulas. Experience with 108 cases. Dis Colon Rectum 39:1097–1101

  88. 88.

    Indian Council of Medical Research (1991) Multicentric randomized controlled clinical trial of Kshaarasootra (Ayurvedic medicated thread) in the management of fistula-in-ano. Indian J Med Res 94:177–185

  89. 89.

    Kronborg O (1985) To lay open or excise a fistula-in-ano: a randomized trial. Br J Surg 72:970

  90. 90.

    Belmonte Montes C, Ruiz Galindo GH, Montes Villalobos JL, Decanini Teràn C (1999) Fistulotomy vs. fistulectomy. Ultrasonographic evaluation of lesion of the anal sphincter function. Rev Gastroenterol Mex 64:167–170

  91. 91.

    Steele SR, Kumar R, Feingold DL, Rafferty JL, Buie WD (2011) Practice parameters for the management of perianal abscess and fistula-in-ano. Dis Colon Rectum 54:1465–1474

  92. 92.

    Swinscoe MT, Ventakasubramaniam AK, Jayne DG (2005) Fibrin glue for fistula-in-ano: the evidence reviewed. Tech Coloproctol 9:89–94

  93. 93.

    Lindsey I, Smilgin-Humphreys MM, Cunningham C, Mortensen NJ, George BD (2002) A randomized, controlled trial of fibrin glue vs. conventional treatment for anal fistula. Dis Colon Rectum 45:1608–1615

  94. 94.

    Ozuner G, Hull TL, Cartmill J, Fazio VW (1996) Long-term analysis of the use of transanal rectal advancement flaps for complicated anorectal/vaginal fistulas. Dis Colon Rectum 39:10–14

  95. 95.

    Ortiiz H, Marzo M, de Miguel M, Ciga MA, Oteiza F, Armendariz P (2008) Length of follow-up after fistulotomy and fistulectomy associated with endorectal advancement flap repair for fistula in ano. Br J Surg 95:484–487

  96. 96.

    Mizrahi N, Wexner SD, Zmora O et al (2002) Endorectal advancement flap: are there predictors of failure? Dis Colon Rectum 45:1616–1621

  97. 97.

    Abbas MA, Lemus-Rangel R, Hamadani A (2008) Long-term outcome of endorectal advancement flap for complex anorectal fistulae. Am Surg 74:921–924

  98. 98.

    Dubsky PC, Stift A, Friedl J, Teleky B, Herbst F (2008) Endorectal advancement flaps in the treatment of high anal fistula of cryptoglandular origin: full-thickness vs. mucosal-rectum flaps. Dis Colon Rectum 51:852–857

  99. 99.

    Balciscueta Z et al. (2017) Rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a systematic review and meta-analysis. Int J Colorectal Dis May 32(5), 599–609.

  100. 100.

    Ellis CN (2007) Clark S (2007) Effect of tobacco smoking on advancement flap repair of complex anal fistula. Dis Colon Rectum. 50(4):459–463

  101. 101.

    Schwandner O (2011) Obesity is a negative predictor of success after surgery for complex anal fistula. BMC Gastroenterol 11:61

  102. 102.

    Gustafsson UM, Graf W (2006) Randomized clinical trial of local gentamicin-collagen treatment in advancement flap repair for anal fistula. Br J Surg 93(10):1202–1207

  103. 103.

    van Okelen RS, Gosselink MP, Thijsse S, Schouten WR (2014) Predictors of outcome after transanal advancement flap repair for high transsphincteric fistulas. Dis Colon Rectum 57:1007–1011

  104. 104.

    Ellis CN, Clark S (2006) Fibrin glue as an adjunct to flap repair of anal fistulas: a randomized, controlled study. Dis Colon Rectum 49:1736–1740

  105. 105.

    Sugrue J, Mantilla N, Abcarian A, Kochar K, Marecik S, Chaudhry V, Mellgren A, Nordenstam J (2017) Sphincter-sparing anal fistula repair: Are we getting better? Dis Colon Rectum 60(10):1071–1077

  106. 106.

    Lin H, Jin Z, Zhu Y, Diao M, Hu W (2018) Anal fistula plug vs rectal advancement flap for the treatment of complex cryptoglandular analfistulas: a system review and meta-analysis of studies with long-term follow-up. Colorectal Dis doi: 10.1111/codi.14504. Epub 2018 Dec 21.

  107. 107.

    N Uribe Millań M Minguez M et al. (2007) Clinical and manometric results of endorectal advancement flaps for complex anal fistula Int J Colorectal Dis 22:259–264.

  108. 108.

    Schouten WR, Zimmerman DD, Briel JW (1999) Transanal advancement flap repair of transsphincteric fistulas. Dis Colon Rectum 42:1419–1422

  109. 109.

    Athanasiadis S, Helmes C, Yazigi R, Kohler A (2004) The direct closure of the internal fistula opening without advancement flap for transsphincteric fistulas-in-ano. Dis Colon Rectum 47:1174–1180

  110. 110.

    Perez F, Arroyo A, Serrano P et al (2006) Randomized clinical and manometric study of advancement flap versus fistulotomy with sphincter reconstruction in the management of complex fistula-in-ano. Am J Surg 192:34–40

  111. 111.

    Van Koperen PJ, Wind J, Bemelman WA, Bakx R, Reitsma JB, Slors JF (2008) Long-term functional outcome and risk factors for recurrence after surgical treatment for low and high perianal fistulas of cryptoglandular origin. Dis Colon Rectum 51:1475–1481

  112. 112.

    Vasilevsky CA, Gordon PH (2007) Benign anorectal: abscess and fistula. In: Wolff BG, Fleshman JW, Beck DE, Pemberton JH, Wexner SD (eds) The ASCRS textbook of colon and rectal surgery. Springer, New York, pp 192–214

  113. 113.

    Tyler KM, Aarons CB, Sentovich SM (2007) Successful sphincter-sparing surgery for all anal fistulas. Dis Colon Rectum 50:1535–1539

  114. 114.

    Van der Hagen SJ, Baeten CG, Soeters PB, van Gemert WG (2006) Long-term outcome following mucosal advancement flap for high perianal fistulas and fistulotomy for low perianal fistulas: recurrent perianal fistulas—failure of treatment or recurrent patient disease? Int J Colorectal Dis 21:784–790

  115. 115.

    Golub RW, Wise WE, Kerner BA, Khanduja KS, Aguilar PS (1997) Endorectal mucosal advancement flap: the preferred method for complex cryptoglandular fistula-in-ano. J Gastrointest Surg 1:487–491

  116. 116.

    Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva K (2007) Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract. J Med Assoc Thai 90:581–586

  117. 117.

    Bleier JI, Moloo H, Goldberg SM (2010) Ligation of the intersphincteric fistula tract: an effective new technique for complex fistulas. Dis Colon Rectum 53:43–46

  118. 118.

    Shanwani A, Nor AM, Amri N (2010) Ligation of the intersphincteric fistula tract (LIFT): a sphincter-saving technique for fistula-in-ano. Dis Colon Rectum 53:39–42

  119. 119.

    Alasari S, Kim NK (2014) Overview of anal fistula and systematic review of ligation of the intersphincteric fistula tract (LIFT). Tech Coloproctol 18:13–22

  120. 120.

    Hong KD, Kang S, Kalaskar S, Wexner SD (2014) Ligation of intersphincteric fistula tract (LIFT) to treat anal fistula: systematic review and meta-analysis. Tech Coloproctol 18:685–691

  121. 121.

    Vergara-Fernandez O (2013) Ligation of intersphincteric fistula tract: what is the evidence in a review? World J Gastroenterol 19:6805–6813

  122. 122.

    Yassin NA, Hammond TM, Lunniss PJ, Phillips RK (2013) Ligation of the intersphincteric fistula tract in the management of anal fistula A systematic review. Colorectal Dis 15:527–553

  123. 123.

    Sirany AM, Nygaard RM, Morken JJ (2015) The ligation of the intersphncteric fistula tract procedure for anal fistula: a mixed bag of results. Dis Colon Rectum 58:604–612

  124. 124.

    Malakorn S, Sammour T, Khomvilai S, Chowchankit I, Gunarasa S, Kanjanasilp P, Thiptanakij C, Rojanasakulet A (2017) Ligation of intersphincteric fistula tract for fistula in ano: lessons learned from a decade of experience. Dis Colon Rectum 60(10):1065–1070

  125. 125.

    Sun XL, Wen K, Chen YH, Xu ZZ, Wang XP (2019) Long-term outcomes and quality of life following ligation of the intersphincteric fistula tract for high transsphincteric fistulas. Colorectal Dis 21(1):30–37

  126. 126.

    Parthasarathi R, Gomes RM, Rajapandian S, Sathiamurthy R, Praveenraj P, Senthilnathan P, Palanivelu C (2016) Ligation of the intersphincteric fistula tract for the treatment of fistula-in-ano: experience of a tertiary care centre in South India. Colorectal Dis 18(5):496–502

  127. 127.

    van der Hagen SJ, Baeten CG, Soeters PB, Beets-Tan RG, Russel MG, van Gemert WG (2005) Staged mucosal advancement flap for the treatment of complex anal fistulas: pretreatment with noncutting setons and in case of recurrent multiple abscesses a diverting stoma. Colorectal Dis 7:513–518

  128. 128.

    Sonoda T, Hull T, Piedmonte MR, Fazio VW (2004) Outcomes of primary repair of anorectal and rectovaginal fistulas using the endorectal advancement flap. Dis Colon Rectum 45:1622–1628

  129. 129.

    Tyler KM, Aarons CB, Sentovich SM (2007) Successful sphincter-sparing surgery for all anal fistula. Dis Colon Rectum 50(10):1535–1539

  130. 130.

    Seow-Choen F, Nicholls RJ (1992) Anal fistula. Br J Surg 79:197–205

  131. 131.

    Ellis CN (2010) Sphincter-preserving fistula management: What patients want. Dis Colon Rectum 53:1652–1655

  132. 132.

    Lunniss PJ, Kamm MA, Phillips RKS (1994) Factors affecting continence after surgery for anal fistula. Br J Surg 81:1382–1385

  133. 133.

    Casillas S, Hull TL, Zutshi M, Trzcinski R, Bast JF, Xu M (2005) Incontinence after a lateral internal sphincterotomy: are we underestimating it? Dis Colon Rectum 48:1193–1199

  134. 134.

    Murad-Regadas SM, Fernandes GO, Ragadas FS et al (2013) How much of the internal sphincter may be divided during lateral sphincterotomy for chronic anal fissure in women? Morphologic and functional evaluation after sphincterotomy. Dis Colon Rectum 56:645–651

  135. 135.

    Lindesy I, Smilgin-Humphreys MM, Cunningham C, Mortensen NJ, George BD (2002) A randomized, controlled trial of fibrin glue vs. conventional treatment for anal fistula. Dis Colon Rectum 45:1608–1615

  136. 136.

    Altomare DF, Greco VJ, Tricomi N et al (2011) Seton or glue for trans-sphincteric anal fistulae: a prospective randomized crossover clinical trial. Colorectal Dis 13:82–86

  137. 137.

    Singer M, Cintron J, Nelson R et al (2005) Treatment of fistulasin-ano with fibrin sealant in combination with intra-adhesive antibiotics and/or surgical closure of the internal fistula opening. Dis Colon Rectum 48:799–808

  138. 138.

    De Parades V, Safa Far H, Etienney I, Zeitoun JD, Atienza P, Bauer P (2010) Seton drainage and fibrin glue injection for complex anal fistulas. Colorectal Dis 12:459–463

  139. 139.

    De Oca J, Millàn M, Jiménez A, Golda T, Biondo S (2011) Long-term results of surgery plus fibrin sealant for anal fistula. Colorectal Dis 14:e12–e15

  140. 140.

    Haim N, Neufeld D, Ziv Y et al (2011) Long-term results of fibrin glue treatment for cryptogenic perianal fistulas: a multicenter study. Dis Colon Rectum 54:1279–1283

  141. 141.

    Buchanan GN, Bartram CI, Phillips RK et al (2003) Efficacy of fibrin sealant in the management of complex anal fistula: a prospective trial. Dis Colon Rectum 46:1167–1174

  142. 142.

    Liao FT, Chang CJ (2018) Initial experience with fibrin glue treatment of anal fistulae in children. Am Surg 84(6):1105–1109

  143. 143.

    Lara FJ, Serrano AM, Moreno JU, Carmona JH, Marquez MF, Pérez LR, del Rey MA, Muñoz HO (2014) Platelet-rich fibrin sealant as a treatment for complex perianal fistulas: a multicentre study. J Gastrointest Surg. 19(2):360–368

  144. 144.

    de la Portilla F, Segura-Sampedro JJ, Reyes-Díaz ML, Maestre MV, Cabrera AM, Jimenez-Rodríguez RM, Vázquez-Monchul JM, Diaz-Pavón JM, Padillo-Ruiz FJ (2017) Treatment of transsphincteric fistula-in-ano with growth factors from autologous platelets: results of a phase II clinical trial. Int J Colorectal Dis 32(11):1545–1550

  145. 145.

    Pérez Lara FJ, Hernández González JM, Ferrer Berges A, Navarro Gallego I, de Los O, Reyes H, Oliva Muñoz H (2018) Can Perianal Fistula Be Treated Non-surgically with Platelet-Rich Fibrin Sealant? J Gastrointest Surg. https://doi.org/10.1007/s11605-018-3932-5

  146. 146.

    Garcia-Olmo D, Herreros D, Pascual I et al (2009) Expanded adipose-derived stem cells for the treatment of complex perianal fistula: a phase II clinical trial. Dis Colon Rectum 52:79–86

  147. 147.

    MD Herreros, M Garcia Arranz, H Guadalajara, P Quintana De la, D Garcia-Olmo, the FATT Collaborative group (2012) Autologous expanded adipose-derived stem cells for the treatment of complex cryptoglandular perianal fistulas: a phase III randomized clinical trial and long-term evaluation Dis Colon Rectum 55:762–772

  148. 148.

    A ba-bai-ke-re MM, Wen H, Huang HG et al (2011) Randomized controlled trial of minimally invasive surgery using acellular dermal matrix for complex anorectal fistula. World J Gastroenterol 16 3279–3286

  149. 149.

    Choi S, Ryoo SB, Park KJ, Kim DS, Song KH, Kim KH, Chung SS, Shin EJ, Cho YB, Oh ST, Kang WK, Kim MH (2017) Autologous adipose tissue-derived stem cells for the treatment of complex perianal fistulas not associated with Crohn's disease: a phase II clinical trial for safety and efficacy. Tech Coloproctol 21(5):345–353

  150. 150.

    Cirocchi R, Trastulli S, Morelli U et al (2013) The treatment of anal fistulas with biologically derived products: is innovation better than conventional surgical treatment? Tech Coloproctol 17:259–273

  151. 151.

    Philandrianos C, Serrero M, Grimaud F, Magalon J, Visée C, Velier M, Francois P, Orsoni P, Magalon G, Grimaud JC, Desjeux A, Véran J, Sabatier F (2018) First clinical case report of local microinjection of autologous fat and adipose-derived stromal vascular fraction for perianal fistula in Crohn's disease. Stem Cell Res Ther 9(1):4–8

  152. 152.

    Norderval S, Lundby L, Hougaard H, Buntzen S, Weum S, de Weerd L (2018) Efficacy of autologous fat graft injection in the treatment of anovaginal fistulas. Tech Coloproctol 22(1):45–51

  153. 153.

    de Weerd L, Weum S, Norderval S (2015) Novel treatment for recalcitrant rectovaginal fistulas: fat injection. Int Urogynecol J 26(1):139–144

  154. 154.

    Tremolada C, Colombo V, Ventura C (2016) Adipose tissue and mesenchymal stem cells: state of the art and Lipogems(R) technology development. Curr Stem Cell Rep 2:304–312

  155. 155.

    Naldini G, Sturiale A, Fabiani B, Giani I, Menconi C (2018) Micro-fragmented adipose tissue injection for the treatment of complex anal fistula: a pilot study assessing safety and feasibility. Tech Coloproctol 22:107–113

  156. 156.

    Hammond TM, Porrett TR, Scott SM, Williams NS, Lunniss PJ (2011) Management of idiopathic anal fistula using cross-linked collagen: prospective phase 1 study. Colorectal Dis 13:94–104

  157. 157.

    Sileri P, Franceschilli I, Del Vecchio BG, Stolfi VM, Angelucci GP, Gaspari AL (2011) Porcine dermal collagen matrix injection may enhance flap repair surgery for complex anal fistula. Int J Colorectal Dis 26:345–349

  158. 158.

    Giordano P, Sileri P, Buntzen S, Stuto A, Nunoo-Mensah J, Lenisa L, Singh B, Thorlacius-Ussing O, Griffiths B, Ziyaie D (2017) Final results of a European multicenter, prospective, observational study of Permacol-collagen paste injection for the treatment of anal fistula. Colorectal Dis. Doi: 10.1111/codi.13715.

  159. 159.

    Schiano di Visconte M, Braini A, Moras L, Brusciano L, Docimo L, Bellio G (2019) Permacol Collagen Paste injection for treatment of complex cryptoglandular anal fistulas An observational cohort study with 2-year follow-up. Surg Innov 26(2):168–179

  160. 160.

    Bayrak M (2018) Altıntas Y (2018) Permacol™ collagen paste injection in anal fistula treatment: a retrospective study with one-year follow-up. Adv Ther. 35(8):1232–1238

  161. 161.

    Fabiani B, Menconi C, Martellucci J, Giani I, Toniolo G, Naldini G (2017) Permacol™ collagen paste injection for the treatment of complex anal fistula: 1-year follow-up. Tech Coloproctol 21(3):211–215

  162. 162.

    Köckerling F, Alam NN, Narang SK, Daniels IR, Smart NJ (2015) Treatment of fistula-in-ano with fistula plug—a review under special consideration of the technique. Front Surg 2:55

  163. 163.

    Narang SK, Jones C, Alam NN, Daniels IR, Smart NJ (2016) Delayed absorbable synthetic plug (GORE® BIO-A®) for the treatment of fistula-in-ano: a systematic review. Colorectal Dis 18(1):37–44

  164. 164.

    Stamos MJ, Snyder M, Robb BW, Ky A, Singer M, Stewart DB, Sonoda T, Abcarian H (2015) Prospective multicenter study of a synthetic bioabsorbable anal fistula plug to treat cryptoglandular transsphincteric anal fistulas. Dis Colon Rectum 58(3):344–351

  165. 165.

    Fisher OM, Raptis DA, Vetter D, Novak A, Dindo D, Hahnloser D, Clavien PA, Nocito A (2015) An outcome and cost analysis of anal fistula plug insertion vs endorectal advancement flap for complex anal fistulae. Colorectal Dis 17(7):619–626

  166. 166.

    O’Riordan JM, Datta I, Johnston M, Baxter NN (2012) A systematic review of the anal fistula plug for patients with Crohn’s or non-Crohn’s related fistula-in-ano. Dis Colon Rectum 55:351–358

  167. 167.

    Garg P, Gong J, Bhatia H, Kalia H, Menon GR (2010) The efficacy of anal fistula plug in fistula-in-ano: a systematic review. Colorectal Dis 12:965–970

  168. 168.

    Bondi J, Avdagic J, Karlbom U, Hallböök O, Kalman D, Šaltytė Benth J, Naimy N, Øresland T (2017) Randomized clinical trial comparing collagen plug and advancement flap for trans-sphincteric anal fistula. Br J Surg. 104(9):1160–1166

  169. 169.

    Xu Y, Tang W (2016) Comparison of an anal fistula plug and mucosa advancement flap for complex anal fistulas: a meta-analysis. ANZ J Surg 86(12):978–982

  170. 170.

    Borreman P, de Gheldere C, Fierens J, Vanclooster P (2014) Can a flap help the plug? or vice versa? Proposing a combined sphincter-sparing anal fistularepair. Acta Chir Belg 114(6):376–380

  171. 171.

    Han JG, Wang ZJ, Zheng Y, Chen CW, Wang XQ, Che XM, Song WL (2016) Cui JJ ligation of intersphincteric fistula tract vs ligation of the intersphincteric fistula tract plus a bioprosthetic anal fistula plug procedure in patients with transsphincteric anal fistula: early results of a multicenter prospective randomized trial. Ann Surg. 264(6):917–922

  172. 172.

    Jayne DG, Scholefield J, Tolan D, Gray R, Edlin R, Hulme CT, Sutton AJ, Handley K, Hewitt CA, Kaur M, Magill L (2019) Anal fistula plug versus surgeon’s preference for surgery for trans-sphincteric anal fistula: the FIAT RCT. Health Technol Assess 23(21):1–76

  173. 173.

    Meinero P, Mori L (2011) Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure for treating complex anal fistulas. Tech Coloproctol 15:417–422

  174. 174.

    Schwandner O (2013) Video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair in Crohn’s disease. Tech Coloproctol 17:221–225

  175. 175.

    Kochhar G, Saha S, Andley M et al (2014) Video-assisted anal fistula treatment. J Soc Laparoendosc Surg 18(e2014):00127

  176. 176.

    Meinero P, Mori L, Gasloli G (2014) Video-assisted anal fistula treatment. Dis Colon Rectum 57:354–359

  177. 177.

    Wałęga P, Romaniszyn M, Nowak W (2014) VAAFT: a new minimally invasive method in the diagnostics and treatment of anal fistulas—initial results. Pol Przegl Chir 86:7–10

  178. 178.

    Mendes CRS, de Ferreira LSM, Sapucaia RA et al (2014) Video-assisted anal fistula treatment: technical considerations and preliminary results of the first Brazilian experience. Arq Bras Cir Dig 27:77–81

  179. 179.

    Selvarajan A (2015) Video-assisted anal fistula treatment (VAAFT): Johor Bahru’s humble beginnings. Int J Integr Med Sci 2:175–177

  180. 180.

    Chowbey PK, Khullar R, Sharma A et al (2015) Minimally invasive anal fistula treatment (MAFT)—an appraisal of early results in 416 patients. Indian J Surg 77:716–721

  181. 181.

    Zarin M, Khan MI, Ahmad M et al (2015) VAAFT: video assisted anal fistula treatment; bringing revolution in fistula treatment. Pak J Med Sci 31:716–721

  182. 182.

    Pini Prato A, Zanaboni C, Mosconi M et al (2016) Preliminary results of video-assisted anal fistula treatment (VAAFT) in children. Tech Coloproctol 20:279–285

  183. 183.

    Seow-En I, Seow-Choen F, Koh PK (2016) An experience with video-assisted anal fistula treatment (VAAFT) with new insights into the treatment of anal fistulae. Tech Coloproctol 20:389–393

  184. 184.

    Jiang H, Liu H, Li Z et al (2017) Video-assisted anal fistula treatment (VAAFT) for complex anal fistula: a preliminary evaluation in China. Med Sci Monit 23:2065–2071

  185. 185.

    Garg P, Singh P (2017). Video-assisted anal fistula treatment (VAAFT) in cryptoglandular fistula-in-ano: a systematic review and proportional meta-analysis. Int J Surg 46:85–91.

  186. 186.

    Adegbola SO, Sahnan K, Pellino G et al (2017) Short-term efficacy and safety of three novel sphincter-sparing techniques for anal fistulae: a systematic review. Tech Coloproctol 21:775–782

  187. 187.

    Emile SH, Elfeki H, Shalaby M, Sakr A (2018) A systematic review and meta-analysis of the efficacy and safety of video-assisted anal fistula treatment (VAAFT). Surg Endosc. 32(4):2084–2093

  188. 188.

    Giamundo P, Geraci M, Tibaldi L, Valente M (2014) Closure of fistula-in-ano with laser–FiLaC: a novel sphincter saving technique for a complex disease. Colorectal Dis 16:110–115

  189. 189.

    Wilhelm A (2011) A new technique for sphincter-preserving anal fistula repair using a novel radial emitting laser probe. Tech Coloproctol 15:445–449

  190. 190.

    Giamundo P, Esercizio L, Geraci M, Tibaldi L, Valente M (2015) Fistula-tract Laser Closure (FiLaC™): long-term results and new operative strategies. Tech Coloproctol 19(8):449–453

  191. 191.

    Wilhelm A, Fiebig A, Krawczak M (2017) Five years of experience with the FiLaC laser for fistula-in-ano management: long-term follow-up froma single institution. Tech Coloproctol 21(4):269–276

  192. 192.

    Terzi MC, Agalar C, Habip S, Canda AE, Arslan NC, Obuz F (2018) Closing perianal fistulas using a laser: long term results in 103 patients. Dis Colon Rectum 61(5):599–603

  193. 193.

    Lauretta A, Falco N, Stocco E, Bellomo R, Infantino A (2018) Anal fistula laser closure: the length of fistula is the Achille’s heel. Tech Coloproctol 22(12):933–939

  194. 194.

    Prosst RL, Joos AK, Ehni W, Bussen D, Herold A (2016) Prospective pilot study of anorectal fistula closure with the OTSC proctology. Colorectal Dis 171(1):81–86

  195. 195.

    Prosst RL, Joos AK (2016) Short-term outomes of a novel endoscopic clipping device for closure of the internal opening in 100 anorectal fistulas. Tech Coloproctol 20(11):753–758

  196. 196.

    Mennigen R, Laukötter M, Senninger N, Rijcken E (2015) The OTSC proctology clip system for the closure of refractory anal fistulas. Tech Coloproctol 19:241–246

  197. 197.

    Gautier M, Godeberge P, Ganansia R, Groupe de Recherche en Proctologie SNFCP France et al. (2015) Easy clip to treat anal fistula tracts: a word of caution. Int J Colorectal Dis 30:621–624.

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Amato, A., Bottini, C., De Nardi, P. et al. Evaluation and management of perianal abscess and anal fistula: SICCR position statement. Tech Coloproctol 24, 127–143 (2020). https://doi.org/10.1007/s10151-019-02144-1

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Keywords

  • Anal
  • Perianal
  • Fistula
  • Fistula-in-ano
  • Abscess
  • Seton
  • Advancement flap
  • LIFT
  • Plug
  • Fibrin glue
  • Implant
  • Biomaterial
  • Horseshoe extension
  • Transsphincteric fistula
  • VAAFT