Position Statement
14054
The treatment of anal fistula: second ACPGBI Position
Statement – 2018
G. Williams*, A. Williams†, P. Tozer‡, R. Phillips‡, A. Ahmad§, D. Jayne¶ and
C. Maxwell-Armstrong**
*Royal Wolverhampton NHS Trust, Wolverhampton, UK, †Guy’s and St Thomas’ NHS Foundation Trust, London, UK, ‡St Mark’s Hospital, Harrow,
London, UK, §Leeds Teaching Hospitals NHS Trust, Leeds, UK, ¶University of Leeds, Leeds, UK, and **National Institute for Health Research
Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
Received 3 December 2017; accepted 16 February 2018
Abstract
It is over 10 years since the first ACPGBI Position
Statement on the management of anal fistula was pub-
lished in 2007. This second edition is the result of scru-
tiny of the literature published during this time; it
updates the original Position Statement and reviews the
published evidence surrounding treatments for anal
Introduction
Anal fistula remains a perplexing condition for the col-
orectal surgeon. The first ACPGBI Position Statement on
this condition was published in 2007 [1] and was devel-
oped after reviewing the literature on this subject span-
ning many decades. Strength of evidence and guidelines
on management were drawn up, but in many instances
the level of evidence used to produce recommendations
was deemed to be low. In the years following that publi-
cation, the literature on anal fistula has expanded, both
with regard to our understanding of its aetiology (still far
from confirmed) and its management, a flurry of new sur-
gical techniques have become available and there is
greater understanding of treatments that were emerging
at the time of publication of the first position statement.
This second Position Statement addresses the infor-
mation that has become available since the first version
and updates guidelines on the management of anal fis-
tula. This Position Statement should be read in con-
junction with the original paper for a complete picture
of the literature on which both statements are based.
Methodology
This Position Statement is based on evidence obtained
from an extensive review of the literature. The authors
Correspondence to: Mr Graham Williams MCh FRCS, Royal Wolverhampton
NHS Trust, New Cross Hospital, Wolverhampton, WV10 0QP, UK.
E-mail: graham.williams4@nhs.net
Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
doi:10.1111/codi.
fistula that have been developed since the original publi-
cation.
Keywords Anal sepsis, anal fistula, aetiology, investiga-
tion, surgical treatment
concentrated on publications after 2005, as the literature
prior to that date was reviewed in the original Position
Statement. Organized searches of the Cochrane Database,
PubMed, MEDLINE and Embase were performed using
keywords relevant to each section of this Position State-
ment. Searches were limited to articles published in Eng-
lish, with a few exceptions. Additional publications were
retrieved from references cited in articles identified from
the primary search of the literature. Relevant papers were
retrieved and studied by members of the writing commit-
tee and incorporated into this review. All evidence was
classified according to an accepted hierarchy of evidence
and recommendations graded A to C on the basis of the
level of associated evidence and/or noted as Good Prac-
tice and/or part of NICE/SIGN recommendation or
Rapid Technology Appraisal (Table 1) [2].
This Position Statement is presented in sections deal-
ing with aspects of pathology, diagnosis and treatment.
The evidence is briefly summarized, where relevant,
under the heading ‘Findings’ and this is followed where
relevant by ‘Recommendations’.
Aetiology
The crypto-glandular theory espoused by Eisenhammer
[3] and Parks [4] remains the most plausible explana-
tion for the initiating event in most cases of idiopathic
anal sepsis, and is widely accepted. This theory proposes
that sepsis originates as an infection in an obstructed
anal gland, usually lying in the intersphincteric space.
5
The treatment of anal fistula (2018 update)
Table 1 Levels of evidence and grades of recommendation.
Level of evidence
I Evidence obtained from a single randomized controlled
trial or from a systematic review or meta-analysis of
randomized controlled trials
IIa Evidence obtained from at least one well-designed
controlled study without randomization
IIb Evidence obtained from at least one other well-designed
quasi-experimental study
III Evidence obtained from well-designed nonexperimental
descriptive studies, such as comparative studies,
correlation studies and case studies
IV Evidence obtained from expert committee reports or
opinions and/or clinical experiences of respected
authorities, case reports
Adapted from Eccles and Mason [2].
*Previous experience and the literature in this area suggests that given the relative lack of evidence for many health care procedures,
expert opinion and professional consensus are likely to be an important part of this process.
Mitalas et al. [5] performed histological studies on the
fistula track in a series of nine patients with chronic fis-
tula undergoing exploration of the intersphincteric
space. None of the tracks contained evidence of anal
gland tissue with mucin-producing cells. However, this
does not disprove the theory, as it is quite plausible that
glandular epithelium was obliterated during the original
septic process. Whereas there has not been any recent
publication confirming this theory, equally there has
not been a publication proposing a more plausible
explanation. Naldini et al. [6] performed endoanal
ultrasound scans on 175 patients with a chronic anal fis-
sure. They demonstrated an intersphincteric fistula in
91 (53%) patients and a transsphincteric fistula in 21
(12%) patients. The relevance of this finding is uncer-
tain. Whilst it suggests a possible alternative aetiology
for an anal fistula, its relevance is more likely to be an
explanation for chronicity of an anal fissure. Why some
people are more prone to anal sepsis remains unex-
plained. Smoking within the last year seems to double
the risk of anal sepsis, but this effect disappears 5 years
after cessation of smoking [7]. What is less clear is the
explanation for persistence of the sepsis with formation
of a fistula.
Anal abscesses are a common surgical emergency, usu-
ally dealt with simply, by adequate incision and drainage.
A recent study examining national hospital activity data
puts the incidence of anal abscess at 20.2 per 100 000
population, although the actual incidence is likely to be
higher as these data do not include patients treated in the
community [8]. Whilst the cryptoglandular theory
assumes that an anal fistula has arisen from the spread of
6 Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
G. Williams et al.
Grade of evidence
A Evidence of Type I or consistent findings from multiple
studies of Type IIa, IIb or III
B Evidence of Type IIa, IIb or III and generally
consistent findings
C Evidence of Type IIa, IIb or III but inconsistent
findings
D Little or no systematic evidence
GP Recommended good practice based on the clinical
experience of the expert group and other professionals*
infection from an anal gland, the rate of fistula formation
following presentation with an anal abscess is low. Two
recent series have reported similar findings, with only a
third of patients presenting with an abscess going on to
form an anal fistula. Furthermore, neither study identified
any associated features that might have increased the risk
of fistula formation, which was lower in diabetic patients
[9,10]. A lower rate of 15.5% for fistula formation follow-
ing an acute anal abscess has been calculated from hospital
activity data [8], although this only included patients
undergoing surgery for an anal fistula and it is likely that
the overall rate is higher as patients not seeking further
medical attention would not have been captured by this
data set. Why some patients go on to establish a fistula
remains uncertain; possible reasons include persistent sep-
sis, epithelialization of the track and hormone-mediated
host response. Traditionally it has been assumed that per-
sistence of sepsis drives fistula formation. However, earlier
studies have shown a paucity of organisms in a fistula track
[11,12] and more recent studies using molecular tech-
niques have shown a lack of bowel-related organisms in
the fistula track. Tozer et al. [13] used in situ hybridiza-
tion to study the microflora of 18 idiopathic (cryptoglan-
dular) fistulas. Surprisingly, bacteria were not found in
close association with the luminal surface of any fistula
track. Similarly, in a series of 10 patients with transsphinc-
teric fistulas, van Onkelen et al. [14] failed to identify bac-
teria in the fistula track using 16S rRNA sequencing in
nine patients. However, immunohistochemistry revealed
the presence of bacterial-derived proinflammatory pepti-
doglycans in all bar one fistula, with evidence of host
response in 6 out of 10. This raises the possibility that
G. Williams et al.
fistula formation and persistence represent a host response
to bacterial cell wall-derived peptidoglycans. It has been
suggested (but with no evidence to confirm this) that cell
wall lipopolysaccharides activate proinflammatory cyto-
kine production, such as tumour necrosis factor a
(TNFa), which could be enhanced by testosterone and
inhibited by oestrogen, providing an explanation for the
lower incidence of anal fistulas in women [15].
Epithelialization of the track has been hypothesized
as a cause for persistence of an anal fistula, but it
remains uncertain whether this is of primary aetiological
importance or a secondary phenomenon. van Koperen
et al. [16] examined 18 fistula tracks and demonstrated
epithelialization in 15 patients, mostly around the inter-
nal opening. However, this series only included patients
with a low fistula undergoing fistulotomy. Mitalas et al.
[5] performed a similar study but on 44 patients with a
higher fistula involving the external sphincter. Epithe-
lialization of the external part of the track was observed
in 11 of 44 (25%) and of the intersphincteric part of
the track in 2 of 11 (22%). Thus, epithelialization is
uncommon within more complex fistulas.
Another conundrum is the mechanism by which sepsis
spreads around the anal canal to form fistulas of differing
complexity. Whilst it is easy to envisage infection spread-
ing along paths of least resistance, such as the intersphinc-
teric space or circumferentially in the ischio-rectal fossas,
it is more difficult to explain the spread of sepsis through
the external sphincter to form a transsphincteric fistula
and to provide a logical explanation as to why some fistu-
las involve little sphincter muscle and others involve most
of the external sphincter. A plausible explanation is that
infection follows fibres of the longitudinal muscle pene-
trating the external sphincter, but this is by no means pro-
ven. Surgical dogma assumes that the ‘deep postanal
space’ is critical to the spread of sepsis around the anus,
and thus the key to eradicating a fistula was thought to be
adequate drainage of this space, as well as control of the
primary track. However, what constitutes the ‘deep post-
anal space’ is disputed, with some going as far as to ques-
tion whether it exists as a distinct entity [17,18]. Recent
radiological and anatomical studies suggest there are sev-
eral potential, or actual, spaces around the anal sphincters
that are likely to be important in the spread of infection.
To confuse the issue further, some of these ‘spaces’ can-
not be identified in the normal anal canal and only
become apparent once sepsis develops and localizes to
that area [18–22].
Imaging
Many imaging modalities are used in the investigation of
anal fistulas, with some subtle refinements in techniques
Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
The treatment of anal fistula (2018 update)
emerging over the last 10 years. Imaging methods include
contrast fistulography, anal ultrasound, magnetic reso-
nance imaging (MRI) and computed tomography (CT).
Anal ultrasound may be carried out with or without three-
dimensional reconstruction and with or without ultra-
sound contrast. MRI has been used with a pelvic phased
array coil, an endoanal receiver coil and with or without
intravenous contrast, and most recently with assessment of
magnetization transfer. Each of these will be reviewed and
compared and recent evidence presented.
Fistulography
Finding
Fistulography provides only very limited information
on fistula anatomy. (Level III)
Recommendation
Fistulography has been superseded by other imaging
modalities in the assessment of cryptogenic anorectal
sepsis. (Grade B)
Fistulography involves the injection of water-soluble
contrast media directly into an external opening of a fis-
tula. This technique is of historical interest and has been
superseded by other imaging techniques. No new infor-
mation to support the use of fistulography has
emerged.
Computed tomography
Findings
CT is inferior to MRI in the assessment of anal fistula,
but newer techniques can provide useful information
in selected patients. (Level III)
Recommendation
Thin-slice spiral CT may be helpful when MRI is
either not available or is contraindicated. (Grade C)
CT scanning is inferior to MRI in its ability to differ-
entiate between fibrosis and active disease and so has
limited value, except when assessing pelvic causes for
extrasphincteric tracks. Multiplanar imaging using thin-
slice spiral CT and intravenous contrast may be helpful
in cases where MRI is either not available or is poorly
tolerated, but the full extent of tracks may be underre-
ported due to failure to fill with contrast or plugging
due to debris [23]. Whilst CT probably has similar sen-
sitivity to MRI for the detection of perianal abscesses, its
role in the assessment of complex anal sepsis is limited.
7
The treatment of anal fistula (2018 update)
Anal endosonography
Findings
Endoanal ultrasound has an established role in the
assessment of anal fistulas. (Level IIa)
Recommendations
Anal endosonography (ultrasound) may be the first
line investigation for patients with an anal fistula that
is suspected to be complex. Patients with recurrent fis-
tula may benefit from anal endosonography, but MRI
will also be required. (Grade B)
Anal endosonography and perineal sonography are
useful adjuncts to the assessment of perianal Crohn’s
disease. (Grade C)
Anal endosonography, using higher-frequency trans-
ducers and volume image acquisition, is an established
investigation for anal sepsis. When this technique is used
by enthusiasts to assess anal sepsis similar accuracy can
be achieved to assessment by endocoil MRI, with an
accuracy of over 80% [24] and near 100% concordance
with surgery for simple cases and 68% for high fistulas
[25]. The height and type of fistula seen on ultrasound
compares well with the findings at examination under
anaesthesia (EUA; 91% accuracy for type and 92% accu-
racy for classification of ‘high’ or ‘low’) [26,27].
Hydrogen peroxide infused into the external opening
of a fistula track acts as an ultrasonic contrast medium to
exaggerate the track and abscesses due to the formation
of the hyper-reflective gas bubbles. This increases the
accuracy and detail of the fistula tracks imaging [28],
and may be very helpful for the delineation of supra-leva-
tor sepsis, which is difficult to locate on clinical examina-
tion alone [26]. However, peroxide may have limited
additional benefit over and above that of multiplanar
ultrasound [29] or noncontrasted trans-perineal scan-
ning [30]. Other ultrasonic contrast agents (e.g. Levo-
vist) have been used [31] but not widely adopted
because of the low cost and easy availability of peroxide
and no additional benefit being seen with the more
expensive agent.
Accurate assessment of the site of the internal open-
ing is dependent upon the criteria used for ultrasonic
definition [32]: budding of sepsis in the intersphincteric
space towards the lumen, penetration of the internal
sphincter and, finally, whether a clear track is seen all
the way through the internal sphincter and into the
lumen [33]. Peroxide enhancement may increase the
detection of internal openings and correct fistula classifi-
cation to above 80% [24,33,34].
8 Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
G. Williams et al.
In recent years there has been significant interest in
assessing Crohn’s anal fistulation with ultrasound.
Detection of the persistence of an internal opening on
anal ultrasound after anti-TNFa treatment for Crohn’s
perianal sepsis may predict recurrence [35] and biologi-
cal treatment guided by the findings of anal ultrasound
may be beneficial [36]; treatment directed by ultra-
sound findings improves the success of fistula surgery
[37] and reduces recurrences in a similar way to MRI
[38]. An endosonographic classification of perianal
Crohn’s disease has been developed, which in a large
series led to a change in management in just under half
of the 150 cases reviewed [39]. The endosonographic
differences in appearances between Crohn’s fistulas and
cryptogenic sepsis have been detailed, with wider
branched tracks and the presence of debris typical in
Crohn’s fistulas [40]. The mean greyscale of a track on
endosonography may also be positively correlated with
the perianal Crohn’s disease activity index and assess-
ment of fistula drainage in Crohn’s disease [41].
The alternative approach of trans-perineal ultrasound
has been used to assess anal fistulas with an accuracy of
up to 86% for the detection of internal fistula open-
ings, both with Crohn’s disease[42] and idiopathic fis-
tulation [43]. Furthermore, transvaginal scanning may
prove to be a useful adjunct to anal scanning for
recto/ano-vaginal fistulation, with 100% positive pre-
dictive value for simple fistulas and 90% for more com-
plex cases [44].
Magnetic resonance imaging
Findings
MRI is an accurate method of imaging anal fistula.
(Level 1)
Recommendation
MRI should be considered in any primary fistula
deemed after clinical or endosonographic assessment
to be complex. It should also be considered in
patients with a recurrent anal fistula. (Grade A)
Magnetic resonance imaging is accepted as the
‘gold-standard’ for the assessment of anal sepsis [1].
Indeed, where there is sepsis detected on MRI but not
at EUA, MRI predicts recurrence of sepsis. Thus MRI
improves clinical assessment by detecting previously
missed secondary extensions and correctly assessing the
level of fistula with respect to the sphincter complex
[45]. This may be further enhanced with novel three-
dimensional modelling systems to show the full extent
of the sepsis in relation to the anal sphincter complex
G. Williams et al.
[46]. The use of endocoils to improve resolution has
been supplanted by the use of pelvic phased array coils,
particularly where more widely extensive sepsis or
supralevator sepsis is suspected [47,48]. It has been
suggested that observer agreement for the reporting of
complex sepsis using MRI is only good in expert cen-
tres, making standardization of the slice planes vital
[49], although expertise can be rapidly attained [50]
with directed education.
Independently of the use of pelvic phased array
coils, variation exists between units in the sequences
used to obtain images and whether or not contrast
agents are used. Rectal gadolinium-DTPA (diethylene-
triamine penta-acetic acid) has been used to help to
identify tracks, with limited benefit [51,52], and saline
has been infused into tracks [53]. The insertion of a
rectal balloon [54] during scanning may improve the
detection of internal openings, although none of these
techniques has been widely adopted. Intravenous
gadolinium-DTPA is widely used to provide dynamic
contrast enhanced MRI (DCEMRI) [55,56] with
equivalent benefit to images obtained by short tau
inversion recovery (STIR) sequences [57]. The use of
contrast aids in the differentiation between nonenhanc-
ing healed tracks and active disease that enhances.
Spencer et al. [56] directly compared sequences to
ascertain those that were most helpful. T1-weighted
sequence scans show anatomical detail together with
sinuses and fistula tracks as hypointense structures,
although T2 scans provide better signal differentiation
between active disease and fibrosis from inactive tracks.
STIR sequences are widely used and considered by
many to be superior to T1- or T2-weighted scans for
the detection and delineation of sepsis [51,58,59].
These have the advantage of suppressing the relatively
high signal from fat in the ischio-anal fossa, and so
highlighting sepsis [51]. It has been suggested that
STIR sequence scanning may not be able to detect
small abscesses that are seen on DCEMRI with T2-
weighted axial images [55,56], but may be better for
the detection of internal openings, especially when
combined with endoanal receiver coils [59]. An alter-
native to STIR sequence scanning is using T2-weighted
scans with spectral fat saturation inversion recovery
(SPIR); when these two techniques were compared,
however, no added advantage was found with SPIR
and sphincter detail was better with STIR [60].
One drawback of using intravenous gadolinium is the
rare complication of nephrogenic systemic fibrosis: the
use of diffusion-weighted MR avoids this, although at
the cost of reduced tissue detail [61,62]. Further
developments using magnetization transfer scanning may
offer an alternative to contrast scans [63]. However,
Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
The treatment of anal fistula (2018 update)
diffusion-weighted scans may be able to assess fistula
activity to produce an ‘apparent diffusion coefficient
map’ [64].
The slice orientation is crucial irrespective of the
sequences used for obtaining images. An initial T2-
weighted sagittal scan should be obtained to orientate
the pelvis such that further axial and coronal scans can
be performed perpendicular and parallel to the long axis
of the anal canal. The most useful planes are axial and
coronal [53,65–67]; scans orientated in the sagittal
plane are of limited value unless ano-vaginal fistulation
is suspected [68] or in distinguishing from a retro-rectal
cyst, with its characteristic appearance. There is a learn-
ing curve for the interpretation of MRI, with an
increase in correct interpretation of up to 50% with
experience [65]. Whilst initial agreement in scan inter-
pretation is acceptable (Ka = 0.7, good agreement)
[59], this can improve to Ka = 0.92 with a short period
of directed training [50].
The use of MRI may predict recurrence of fistula
disease. Where EUA fails to find and treat sepsis sug-
gested on imaging, the sepsis often recurs, with the
recurrence located at the site predicted by the preoper-
ative imaging [69,70]. In addition, MRI classification
of fistulas into simple and complex is able to predict
the chance of recurrence much more accurately than
EUA alone (positive predictive value 73% vs 57%) [71].
When a surgeon always acts on the result of preopera-
tive MRI, then the recurrence rate for complex fistulas
is 16%, compared with 57% where the results of imag-
ing are disregarded [72]. It has been suggested that
preoperative MRI assessment has the potential to alter
surgical practice in up to 10% of cases if used prospec-
tively for primary fistulas [73] and 21% if used in a
mixed population of primary and secondary fistulas and
patients with Crohn’s disease [74].
Several groups have devised grading systems based
on MRI. The St James’ system relates to the fistula
anatomy [75] and shows good concordance with surgi-
cal findings [76]. Van Assche et al. [77] have devel-
oped a MRI scoring system which includes assessment
of the type and number of tracks, the presence and
type of extensions, collections and rectal wall thicken-
ing and the signal intensity on T2-weighted scans. This
latter scoring system has been criticized for being
insensitive to changes in clinical state because the vari-
ous factors which make up the score do not always
change concordantly with each other. Clinical and radi-
ological evaluation in patients with Crohn’s anal fistula
treated with biological agents has shown that the latter
lags behind the former by 12 months [78]. Neverthe-
less clinical improvement is mirrored by improvement
in MRI appearances up to 1 year [79,80] and MRI
9
The treatment of anal fistula (2018 update)
may be valuable in predicting those patients who will
relapse following treatment with anti-TNF treatment
[81]; studies evaluating the importance of changes in
the volume of the fistula track and T2 signal intensity
in predicting relapse are under way.
MRI is not always well tolerated, it is not universally
available and, when compared with anal endosonogra-
phy, it is time-consuming. In general use, MRI is prob-
ably superior to anal ultrasound, with concordance with
surgery for ultrasound of 80% and MRI 90% [65,67–
69,82,83]. Ultrasound may be better at locating inter-
nal openings than non-endocoil MRI [82], but it does
have the drawback of not being possible in the presence
of canal stenosis [84], and there are difficulties in differ-
entiating old tracks from new sepsis, and misinterpreta-
tion of intersphincteric sepsis as transsphincteric because
of acoustic shadowing [85]. The role of anal ultrasound
in assessing anorectal fistulation is uncertain; some
report equal value with MRI (endocoil) [86] whilst
others suggest limited value other than to demonstrate
combined sphincteric defects [87].
In summary, when comparing the different methods
of imaging anorectal sepsis it is important to concen-
trate on the questions that need to be addressed, not
forgetting that not all anal fistulas need investigation
as the majority are primary, simple and low and can
be fully assessed clinically and treated with surgery.
Anal ultrasound has been shown to be able to differ-
entiate between complex and simple sepsis [88–91].
Clearly not all patients need MRI, but there is strong
evidence for the value of MRI assessment to direct
surgery for recurrent fistulas. Surgery directed by pre-
operative MRI has a recurrence rate of 16% compared
with surgery where MRI is not acted upon (recurrence
rate 57%) [72]. Primary cases that are suspected to be
complex should have anal ultrasound scanning where
local expertise exists, and if features of complex fistula-
tion or secondary extensions are present then MRI
should be obtained. All recurrent fistulas, except those
with clearly simple recurrence on anal ultrasound,
should have MRI. Sequences used should include T1
images to give details of sphincter anatomy and scans
with either fat suppression (STIR, SPIR) or dynamic
contrast enhanced scans (DCEMRI). The scans should
be orientated along and orthogonal to the long axis of
the anal canal (and not the long axis of the body),
facilitated by a T2 scout sagittal scan in the mid coro-
nal position. Axial and coronal scans are of most bene-
fit although sagittal images are of use in cases of ano/
rectovaginal fistulation. Recent scoring and grading
systems may prove useful in following response to bio-
logical treatment in Crohn’s fistulas, and MRI images
should be used to guide surgery at the time of EUA.
10 Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
G. Williams et al.
Treatment
Surgery remains the mainstay of treatment of a non-
Crohn’s anal fistula, the aim being to cure the fistula
while at the same time preserving anal sphincter func-
tion. Various surgical approaches remain in use, indicat-
ing that there is no ideal procedure applicable to every
patient. Since publication of the first edition of this
Position Statement [1] a number of new, minimally
invasive approaches to surgical treatment have emerged.
Informed consent involves discussing surgical options
and their likely outcome with a patient, as well as the
consequences of any complications. This should include
discussion about the risk of recurrence/persistence of
the fistula as well as alteration in anal control. A fistula
can vary in complexity from being simple, involving
only a small proportion of the anal sphincter, to com-
plex, with multiple tracks involving more of the anal
sphincter. The surgeon should be able to identify the
degree of complexity of the fistula and plan surgery
accordingly. Complex fistulas should be treated by an
experienced surgeon, particularly when they are associ-
ated with Crohn’s disease. (Level of evidence: Level IV,
Grade GP).
Fistulotomy
Findings
Fistulotomy has an extremely high (95%+) cure rate,
as long as all tracks are dealt with. Sphincter division,
even for low and intersphincteric fistulas, carries
approximately a one in three chance of inadvertent
loss of flatus and slight passive soiling, largely deter-
mined by internal sphincter division. Whilst division of
the anorectal ring will lead to frank faecal inconti-
nence, in expert hands laying open larger amounts of
the external sphincter (preserving at least 2 cm of
cephalad sphincter) has outcomes similar to those after
laying open of a low anal fistula. (Level III)
Recommendations
As a general rule, fistulotomy results in a reliable cure
with good patient satisfaction, where 2 cm of proxi-
mal muscle remains intact and in the presence of a
‘normal’ bowel habit, without urgency and in the
absence of irritable bowel symptoms. (Grade C)
Fistulotomy not only involves completely laying open
the fistula from one opening to the other and division
of all the anal sphincter below it, but also identification
of all secondary tracks and their adequate drainage. It
G. Williams et al.
results in healing in more than 95% of patients [92,93],
but concerns regarding impairment of ‘continence’ inhi-
bit surgeons and patients from selecting this option.
The word ‘incontinence’ encompasses a wide spectrum,
from the odd stain in the underwear, through inadver-
tent passage of flatus, to frank and devastating loss of
stool with the prospect of a colostomy. Part of the con-
sent process should include a detailed description of the
various scenarios, rather than use the blanket-term ‘in-
continence’. Certainly, incontinence has a negative
impact on quality of life [94] but so too does fistula
recurrence [95] and an endless cycle of failure and
recurrence is to be avoided as assiduously as faecal
incontinence. Early on in a patient’s surgical course
even slight departure from a prior norm can be unac-
ceptable; later on, after failed procedures, the trade for
cure of the fistula is often welcomed.
Assessing the likely degree of impairment of conti-
nence associated with fistulotomy before it takes place is
one of the great difficulties in proctology, and numer-
ous studies have been directed at this question. Whereas
division of the entire sphincter complex will result in
total incontinence, preservation of the anorectal ring
alone will prevent major incontinence in most patients
[96]. It has been argued that progressively greater
sphincter division leads to progressively greater impair-
ment of continence. However, incremental functional
loss has never been demonstrated and, as with liver
resection, it is the volume of muscle left behind that is
important and what determines continence.
When division of the internal sphincter alone is
compared with division of both internal and external
sphincter, the same degree of impairment of conti-
nence is seen [97]. Manometric data support this,
demonstrating that maximum resting pressure
decreases similarly whether the internal sphincter alone
or both sphincters are divided [97]. In the same
study, external sphincter division did lead to a reduc-
tion in maximum squeeze pressure, but as long as a
minimum length of external sphincter is maintained a
consistent level of impairment can be predicted,
regardless of the degree of internal and/or external
sphincter division performed. There is a one in three
risk of flatus incontinence and marking of the under-
wear [92,93] that is governed by the internal sphinc-
ter. The literature on lateral anal sphincterotomy for
fissure supports this assertion [98]. There are specific
groups of patients in whom the minimum amount of
remaining muscle required is greater, as a consequence
of looser/more frequent stool now, or the risk of it
in the future, such as in irritable bowel syndrome or
Crohn’s disease, or in whom the length of muscle
present will not permit further division, such as an
Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
The treatment of anal fistula (2018 update)
anterior fistula in a woman [99]. Thus careful patient
selection is crucial.
Determining the height of a fistula can also present a
challenge. Some tracks travel obliquely cephalad, mean-
ing that the internal opening gives a falsely low impres-
sion of the height of the track through the external
sphincter [100]. It takes experience to be able to feel
the internal opening of a fistula, but the information is
vital as only with it can an estimate be made of how
many centimetres of muscle will be preserved after lay-
ing open: the presence of a seton may help. The inter-
nal opening can be identified directly at operation, but
if caudal/spinal anaesthesia has been used the proximal
sphincter loses its tone and a estimation of length may
be difficult. Light general anaesthesia, which can further
be lightened, thereby inducing muscle contraction,
serves to circumvent this problem.
Fistulotomy in acute anorectal sepsis
Findings
Immediate fistulotomy, although associated with a
lower recurrence rate than simple incision and drai-
nage, carries a risk of misjudgement of the depth of
the fistula. (Level I)
Recommendations
Immediate fistulotomy should be undertaken only by
experienced surgeons in patients in whom the internal
opening is obvious without probing, and the fistula is
‘simple’. (Grade A)
A more conservative practice of simple abscess drai-
nage in the majority of circumstances is safest. (Grade
GP)
Two meta-analyses have considered the question of
immediate fistula treatment at acute anorectal abscess
drainage. Quah et al. [101] examined five randomized
controlled trials (RCTs) and a subsequent Cochrane
review added a sixth non-English language trial [102].
Both identified lower recurrence rates of anorectal sep-
sis (abscess or fistula) with immediate fistula treatment.
This is perhaps not too surprising. In the five studies
analysed by Quah et al. [101], patients treated with
abscess drainage alone presented with subsequent
abscess or fistula in between 14% and 40% of cases,
whereas immediate fistula treatment reduced recurrence
to between 0% and 10%. Impairment of continence
varied significantly in the immediate treatment arm
across the studies, from as high as 40% in some to
zero in others. Two of the five studies found a
11
The treatment of anal fistula (2018 update)
significant difference in impairment of continence
between the two study arms, but at meta-analysis no
such difference was seen. Both therefore advocate
immediate fistula treatment. However, a more cautious
approach may be preferable, particularly in less experi-
enced hands.
The literature, including observational studies as well
as these RCTs, consistently describes a lower ‘recurrence’
rate in patients in whom immediate fistulotomy is under-
taken. But some 40% of patients with an abscess where
culture revealed gut-related organisms never go on to
develop a fistula [103], which suggests potential
overtreatment in a significant minority. Ho and Tang
studied only patients with an abscess who had a demon-
strable internal opening, and in the abscess drainage only
arm, just 10 of 49 patients had recurrence [104]. What
this means is that the remaining 39 patients (80%) would
have been exposed to the risks of fistulotomy without ben-
efit.
A reasonable compromise may be for an experienced
surgeon to undertake immediate fistulotomy in simple
fistulas when the abscess is recurrent and where drai-
nage alone seems unlikely to resolve matters. But this
relies on the detailed preoperative counselling, usually
employed in the outpatient clinic, and which is less
likely to be successful for a patient suffering a painful
acute abscess and having little time to consider the
options prior to urgent surgery.
Fistulotomy in inflammatory bowel disease
Findings
Most surgeons would avoid fistulotomy in a patient
with Crohn’s disease and an anal fistula. (Level III)
Recommendations
Careful consideration should be undertaken before
performing fistulotomy in Crohn’s disease, even for a
‘low’ fistula. (GP)
Fistulotomy in Crohn’s disease is uncommon, and a
recent survey of UK surgeons indicated that around
half would occasionally consider fistulotomy but only
3% did so frequently and more than a third would
never do so [105]. van Koperen et al. [106] undertook
fistulotomy in a group of patients with low fistulas in
Crohn’s disease with a recurrence rate of 17% and
impairment of continence in two-thirds, both worse
than the outcomes seen in idiopathic fistulas, which
may explain the reticence of most UK surgeons to per-
form fistulotomy. This particular group of complex
12 Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
G. Williams et al.
fistulas have been considered in more detail in another
publication [105].
Marsupialization
Findings
Marsupialization after fistulotomy is associated with a
significantly shorter healing time (Level I) and a
shorter duration of wound discharge. (Level I)
Recommendations
The wound edges of the laid open fistula track should
be marsupialized to aid healing and reduce wound dis-
charge. (Grade A)
Marsupialization is a simple procedure which
improves wound healing. It is also used as part of the
wound shaping which some surgeons use to prevent
early bridging and allow adequate drainage of the
wound. Four randomized trials have demonstrated that
marsupialization of the fistulotomy wound reduces time
to wound healing [107–110]. Ho et al. [108] demon-
strated a faster healing time (6 vs 10 weeks, P < 0.001)
in 103 patients randomized to fistulotomy vs fistulo-
tomy with marsupialization. A higher squeeze pressure
was also seen in the marsupialized group, but the clini-
cal relevance of this is unclear. Pescatori et al. [110]
studied 46 patients in the same way and found less
bleeding as well as a quicker reduction in wound size in
the marsupialized group. More recently, Jain et al.
[109] randomized 40 patients to fistulectomy or fistulo-
tomy with marsupialization, demonstrating faster
wound healing (around 5 weeks vs around 7,
P = 0.003) and earlier cessation of wound discharge.
Chalya et al. [107] found similar results in 162 patients
randomized between the same procedures.
Setons
The evidence supporting the use of setons in the man-
agement of anal fistulas was comprehensively reviewed
in the original position statement on anal fistula [1].
Essentially a seton can be used in three main ways in
the treatment of an anal fistula, with myriad variations
of technique between published series. The seton can
be inserted and tied loosely over the sphincter to drain
the track and allow sepsis to settle before it is removed,
in the hope that the fistula will heal (loose seton). The
seton can be used to divide the sphincter muscle slowly
to eradicate the fistula (cutting seton) and the seton can
be used as a long-term drain to provide palliation of
G. Williams et al.
symptoms from the fistula, where other techniques are
deemed unsuitable.
Loose seton
Findings
A loose seton, used as sole treatment, results in fistula
healing in only a small proportion of patients. Higher
healing rates are achieved by staged fistulotomy after a
period of seton drainage. (Level III)
A loose seton can be used to treat ‘high’ and complex
anal fistulas with low risk to diminishing anal control.
(Grade B)
A number of series of patients treated with a loose
seton continue to be reported, often with subtle varia-
tion in technique and all highlighting the relative
safety of this technique as regards alteration in anal
control. However, convincing evidence of fistula heal-
ing following simple removal of a loose seton is scant,
and often an additional procedure is required to
achieve fistula healing. Galis-Rozen et al. [111]
reported a series of 77 patients, 17 of whom had
Crohn’s disease and were treated with a loose seton
alone. Of the 60 patients with non-Crohn’s fistulas,
only 4 healed without further surgery and 20 (46%)
healed following second-stage fistulotomy. However, a
similar proportion of patients either had recurrence or
did not heal following seton placement, possibly
reflecting the complexity of fistulas included in this
series. In a similar manner, Lim et al. [112] described
an intriguing modification of the loose seton tech-
nique. The primary track was re-routed into the inter-
sphincteric space, by dividing the mucosa and internal
sphincter below the internal opening and placing a
seton around the external sphincter in the intersphinc-
teric plane, before closing the internal opening,
mucosa and divided internal sphincter over the seton.
Fifty-three patients were treated by this technique,
with a reported recurrence rate of 13% and inconti-
nence reported by two patients. However, follow-up
was mostly by telephone contact and no clinical assess-
ment was made to confirm healing of the fistula. An
alternative approach was reported by Pinedo et al.
[113] in 18 patients with transsphincteric fistulas. The
external part of the track was laid open to the outer
surface of the external sphincter and an internal
sphincterotomy was performed to lay open the inter-
sphincteric element of the track. A loose elastic seton
was inserted in the remaining track through the exter-
nal sphincter and removed when the internal opening
had migrated to the anal verge. All setons were
Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
The treatment of anal fistula (2018 update)
eventually removed after a median of 4 months; how-
ever, it is not clear how many fistulas healed, although
there was deterioration in anal control reported. Sub-
has et al. [114] used a silk seton as a loose seton,
which the patient was instructed to rotate through
360° in each direction on a daily basis. Twenty-four
patients were followed for a mean of 45 months (but
only by questionnaire and telephone interview), with
18 (75%) fistulas healing, 9 once the seton extruded
spontaneously and 9 after low fistulotomy of the resid-
ual track: two patients developed incontinence of liq-
uid stool only. Kelly et al. [115] followed a series of
200 patients treated with a polybutylate (EthibondTM)
suture, with a recurrence rate of 6% and a low rate of
incontinence. However, follow-up was short
(6 months) and detail of how changes in anal control
were defined and assessed was lacking. Furthermore,
although the loose seton controlled symptoms, most
patients ended up requiring a second procedure to lay
open the residual fistula track. Follow-up is not
described in any detail and four patients (6%) were
said to have experienced ‘minor’ incontinence.
Cutting (tight seton)
Findings
A tight seton inserted into a transsphincteric fistula
will result in healing in upwards of 90% of patients.
There is some risk of diminishing anal control that is
influenced by the height of the internal opening and
the amount of muscle encompassed in the seton.
(Level III)
Recommendations
A tight seton can be used to treat selected ‘high’ and
complex anal fistulas where other techniques are either
not suitable or have failed. The patient should be
counselled carefully as to the risk of permanent incon-
tinence. (Grade B)
A tight seton has been used where a surgeon is
unwilling to perform fistulotomy because it is thought
that too much sphincter will be divided in the process
and the risk of incontinence is high. A variety of tech-
niques have been described, all with the same principle,
namely slow division of the sphincter encompassed by
the seton, with progressive caudal migration of the track
and eventual extrusion of the seton. Much is made of
the theory that this slow division with a foreign material
generates fibrosis around the sphincter as it is divided,
limiting separation of the sphincter ends and healing of
the muscle cephalad to the seton as it descends the anal
13
The treatment of anal fistula (2018 update)
canal. This is in contrast to the springing open of the
sphincter ends that occurs with primary fistulotomy.
Attractive as this theory sounds, there is little or no evi-
dence to substantiate improved sphincter morphology
and function over immediate fistulotomy. Anecdotal
comparison of ultrasound appearances of the sphincters
after cutting seton suggest less sphincter separation than
after fistulotomy, but it is uncertain if like is being com-
pared with like [116]. Rosen and Kaiser [117] used
data from Ritchie et al. [118] to demonstrate an associ-
ation between the rate of incontinence and the interval
between seton tightening, which they interpreted as
supporting evidence that slow sphincter division pre-
serves sphincter function. However, this requires a large
leap of faith, as the data used were very heterogeneous,
with different definitions of incontinence and periods of
follow-up.
Evidence in favour of the use of a cutting seton is
still based on case series, and no specific randomized
trial of tight setons vs other surgical options has been
performed. Most studies suffer from a number of
flaws, usually involving the definition of end-points,
limited follow-up and low numbers. A variety of differ-
ent materials have been used as tight setons, including
silk [119], rubber bands, rubber surgical glove
[116,120], silastic vessel sloop [121] and electrical
cable tie [122]. Each modification is designed to make
tightening the seton simple as well as avoiding the
need for a general anaesthetic. Similarly, some authors
perform internal sphincterotomy prior to seton inser-
tion [123,124] and others encompass both the exter-
nal and internal sphincters in the seton, after removing
skin and anoderm beneath the seton [116]. Whichever
technique is employed, the internal sphincter will even-
tually be divided by the seton as it cuts through the
fistula track and overlying sphincter. Vial et al. [123]
performed a meta-analysis on a number of case series
looking at recurrence rates and alteration in anal con-
trol after use of a cutting seton, with and without
sphincterotomy at time of seton insertion. They con-
cluded that recurrence rates were similar (at less than
5%), but overall incontinence was higher after sphinc-
terotomy (25%) than after seton insertion without
sphincterotomy (6%). However, these results should be
interpreted with considerable caution as the studies
were very heterogeneous, with different follow-up peri-
ods and different methods of assessing changes to
incontinence.
Raslan et al. [119] collated 51 patients treated with
a tight silk seton, with a recurrence rate of 10% and
incontinence to flatus of 16% and liquid stool of 6%.
However, details as to the anatomy of the fistulas trea-
ted and how continence was assessed are absent and
14 Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
G. Williams et al.
follow-up duration was not specified, but was likely to
have been short. A similar study by Kamrava et al.
[125] used silk, but tightening of the seton was con-
trolled by the patient. Recurrence was 10% and only 1
of 47 patients was reported to have new problems with
control, although definitions used for assessing control
were loose and follow-up was short. Using a thin elec-
trical cable tie as a seton is intriguing: Memon et al.
[122] reported a series of 79 patients with transsphinc-
teric or suprasphincteric fistulas, with a recurrence rate
of 5% and no reported change in continence. However,
no details were given as to the level of discomfort expe-
rienced by the patients, who required on average six
tightenings of the seton and an average of 12 weeks for
healing to occur. Hammond et al. [121] used a silastic
vessel and nerve sloop as a ‘snug’ seton in a series of 29
patients. The seton cut through the enclosed tissue in
15 patients, but 14 patients required a superficial fistu-
lotomy to finally remove the seton. There were no
recurrences identified, and 10 patients (34%) experi-
enced early minor incontinence, which persisted in 4 of
16 patients followed for a median of 42 months. Leven-
toglu et al. [120] used a rubber glove as a ‘hybrid’
seton; this was not tied as tightly as a traditional cutting
seton with the same intention as Hammond et al.
[121]. Side tracks were dealt with by a modified Hanley
technique, using Penrose drains. With this technique
there was one recurrence over a mean follow-up of
20 months and no significant change in the Cleveland
continence score. Ege et al. [116] used the cuff from a
rubber glove as a ‘hybrid’ seton, tied snugly over the
denuded external sphincter following internal sphinc-
terotomy. They followed 128 patients, with the seton
extruding after a mean of 19 days, suggesting that
many fistulas were low. Complete healing occurred at
3 months in all patients and only two patients returned
with a recurrent fistula after a minimum of 12 months’
follow-up. However, in common with other studies, it
is unclear as to how tightly the seton was tied over the
sphincter. Izadpanah et al. [124] described a technique
they called a ‘pulling seton’ in a large series of 201
patients in whom they divided the internal sphincter
and the external part of the fistula, before tying a seton
over the remaining external sphincter muscle. The
patient was instructed to tug on the seton four times a
day. Using this technique, they reported a recurrence
rate of 5% and no permanent gas or faecal incontinence.
However, follow-up was short and postoperative assess-
ment of continence was limited. Rosen and Kaiser
[117] reported on 121 patients with a transsphincteric
fistula treated by tight seton. Initial healing occurred in
90% of patients, rising to 98% after further surgical pro-
cedures. Interestingly, 17 patients with preexisting
G. Williams et al.
continence problems improved following surgery, indi-
cating that the presence of a fistula can cause continence
problems (possibly by discharge through the track).
Only eight patients developed new problems with anal
control. These excellent results should be interpreted
with some caution as follow-up of these patients was
short (mean 5 months).
In summary, a variety of materials have been used as
a cutting seton, with most series reporting successful
healing of the fistula and recurrence rates of the order
of 10% after short-term follow-up. It is uncertain if
internal sphincterotomy is a necessary part of the proce-
dure. It is likely that sphincter division (even slow divi-
sion) will inevitably lead to some diminution in anal
control, which may not become apparent immediately.
Ritchie et al. [118] collated a large number of series
and calculated an average incontinence rate of the order
of 12%.
Advancement flaps
Advancement flap surgery is a well-established tech-
nique with reliable outcomes in experienced hands.
The technique should be considered in patients in
whom fistulotomy would result in a compromise to
continence that would be deemed unacceptable to the
patient, and with a track morphology that is likely to
yield success. An advancement flap may also be used to
close an anorectal or recto-urethral fistula. As well as
disconnecting the fistula from the gut, a flap technique
is effective as it brings a layer of healthy native tissue
to cover the internal opening, following control of sep-
sis. Adequate vascularity of the flap and tension-free
anastomosis, placed well beyond the site of the (ex-
cised) internal opening, are key to success. Advance-
ment flaps can be taken from the rectum (transanal
advancement flap) or from the perianal skin (cutaneous
advancement flap). Also described are the transanal
sleeve advancement flap (TSAF) and the Delorme’s-
style advancement flap. This is similar to the TSAF
but, as in the Delorme’s procedure for rectal prolapse,
after mucosal mobilization the muscle wall is advanced
and sutured down to the internal anal sphincter distal
to the internal opening of the fistula. This procedure is
facilitated by internal intussusception and would not
be a tension-free repair without it [126]. The presence
of internal intussusception or perineal descent may
facilitate advancement flap repair.
A number of factors have been identified as risk fac-
tors for failure of an advancement flap procedure. These
include, smoking [127,128], a flap for a recurrent fis-
tula [127], Crohn’s disease [129], horseshoe abscess
[130] and high BMI [131]. Differing study populations
Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
The treatment of anal fistula (2018 update)
may explain heterogeneity in the significance of risk fac-
tors identified in different studies.
Transanal advancement flap
Findings
The success rate of transanal advancement flap is of
the order of 60%. (Level III)
Recommendations
Transanal advancement flap can be used to treat an
anal fistula where simple fistulotomy is thought likely
to result in unacceptable impairment of continence.
(Grade B)
The transanal rectal advancement flap procedure has
several advantages over other treatments for anal fistula.
Division of the external sphincter is avoided with less
risk of impairment of continence, and defects of the
contour of the anal canal, such as a keyhole deformity,
are avoided and healing is quicker than after fistulo-
tomy. Additional procedures can be incorporated into
the operation, such as sphincteroplasty, without the
need for a protective colostomy. Failure of the repair
does not usually lead to worse symptoms, although the
internal sphincter at the level of the anorectal junction
will have been disrupted to a certain extent and the anal
canal will be somewhat more rigid as a result of scar tis-
sue. This could result in functional impairment.
Relative contraindications to the transanal rectal
advancement flap procedure include: the presence of
proctitis – especially in patients with Crohn’s disease;
undrained sepsis and⁄or persisting secondary tracks; an
anorectal fistula with a diameter > 3 cm; malignant or
radiation-related fistula; a fistula of less than 4 weeks’
duration; and an associated stricture of the anorectum
[132]. Stricture, tissue loss and scarring of the anorec-
tum may impair the surgeon’s access and may make flap
repair technically impossible.
The surgical technique for endoanal advancement flap
procedures has been described in earlier publications
[133–135] and was summarized in the previous position
statement [1]. Whilst many surgeons would use mechani-
cal bowel preparation prior to surgery, and consider the
use of a defunctioning stoma to cover the procedure,
there is no evidence base to support these approaches. A
semi-circular flap is most commonly used as this avoids
ischaemia at the corners. The majority of authors describe
a U-shaped flap, while a minority use an inverted U-
shaped flap. The flap consists of mucosa, submucosa and
a varying degree of circular muscle from none to the full
rectal wall thickness, depending on the author. There has
15
The treatment of anal fistula (2018 update)
been limited evidence from individual studies to support
the logical assertion that more muscle means greater vas-
cularity and therefore success, at the cost of a greater risk
of impairment of continence, but pooled data from a
recent meta-analysis suggest that this is correct [136].
The transanal sleeve advancement flap procedure
The TSAF takes the concept of flap advancement one
step further by mobilizing the circumference of the anal
canal. It has been used for a subgroup of patients with
severe complex fistulas associated with Crohn’s disease
[137]. The technique is similar to the transanal flap pro-
cedure described above, but in addition a 90–100% cir-
cumferential incision is made at or just below the dentate
line to create a sleeve of the full thickness of the bowel
wall. This is then mobilized proximally into the suprale-
vator space until sufficient mobility is achieved to allow
the flap to be advanced distally into the anal canal with-
out tension. Its distal edge is then sutured with absorb-
able sutures to the epithelium of the anal canal below the
level of the internal opening. This technique may offer an
alternative in selected patients with fistulation in Crohn’s
disease without proctitis, for whom the only alternative is
proctectomy with permanent stoma.
The cutaneous advancement flap procedure
Findings
The cutaneous advancement flap procedure has a simi-
lar success rate to endoanal flap, but the theoretical
risk of avoiding ectropion formation. (Level III)
Recommendations
The cutaneous advancement flap procedure is an alter-
native to rectal advancement flap repair of a high fis-
tula. (Grade B)
The cutaneous advancement flap appears to have a
similar success rate to endoanal flap procedures, with
the theoretical advantage that by moving skin into the
anal canal, mucosal ectropion is avoided [138–141].
The technique for the procedure has been described
elsewhere [138–141].
Postoperative management of flap procedures
There is no consensus on the role of anti-diarrhoeal
agents or antibiotics in the early postoperative period.
Normal anal wound management should be carried out.
Fistula recurrence after advancement flap procedures
It is difficult to compare published series as there is
often great variation in the type and complexity of
16 Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
G. Williams et al.
fistula, and the methods of repair. Long-term follow-
up is essential for assessing recurrence accurately.
Advancement flap procedures are safe. Early case series
suggested efficacy in around 70% of patients [132–
134,138–144]. However, more recent randomized
controlled trial data, often vs the anal fistula plug, and
larger series, suggest healing in a smaller proportion,
perhaps of the order of 50–60% [145–147]. A recent
multicentre randomized trial of 94 patients from Scan-
dinavia found a primary success rate (defined as clinical
healing), at a median of 12 months of follow-up, of
62% of 40 patients. A full-thickness flap was used and
patients had a single, non-complex high transsphinc-
teric track and after only a single previous fistula oper-
ation (probably seton insertion). The comparator
group, treated with a fistula plug, achieved clinical suc-
cess in only a third of patients. MRI confirmation of
healing was not reported in either arm [148]. This
study represents a robustly performed assessment of
transanal rectal advancement flap surgery in well-
selected patients, and is a realistic report of the tech-
nique. A recent meta-analysis including 26 studies and
1655 patients indicated an increasing success rate
(avoidance of recurrence) with increasing thickness of
the flap raised, although there was significant hetero-
geneity between studies [136]. The pooled recurrence
rate was 21%, but ranged from 0% to 47%. Core out
vs curettage of the track did not influence outcome.
Continence impairment
There is great heterogeneity in how continence is assessed
following advancement flap surgery. Early studies found
little impairment of continence but some authors suggest
minor incontinence may occur in around a quarter of
patients [149]. Meta-analysis suggests a greater likelihood
of continence impairment with full-thickness flaps (20%)
than mucosal or partial thickness flaps (10%), although
the impairment was generally minor [136].
Fibrin glue
Findings
The use of fibrin glue to treat anal fistulas is associated
with variable success, but does not threaten conti-
nence. It remains uncertain as to which fistulas are
suitable for fibrin glue treatment. Success (fistula heal-
ing) is low when the fistula track is short. (Level I)
Recommendations
With variable and mostly low rates of healing, fibrin
glue is not recommended for routine use in anal
G. Williams et al. The treatment of anal fistula (2018 update)

fistulas, but may be considered where other surgical continence score in the seton group. Many studies have
options are not feasible. (Grade C) investigated the use of repeat glue application to
increase healing rates, even up to four applications
Various autologous and commercial preparations of
[166]. A prospective study of fibrin glue for simple
fibrin glue have been used to treat anal fistulas. Autolo-
transsphincteric and intersphincteric fistulas showed that
gous glues are formed from the patient’s own blood,
repeat glue treatment decreased the overall recurrence
whilst commercially available glues are a mixture of clot-
rate from 23% to 7.6% [167]. Conversely, other authors
ting factors, aprotinin and calcium (Beriplast; CSL
have reported that repeated applications of fibrin glue
Behring, Pennsylvania, USA; Tisseel; Baxter Healthcare,
are unlikely to succeed [168] and other studies have
Deerfield, Illinois, USA), or are synthetic glues, such as
shown an adverse outcome when fibrin glue is com-
cyanoacrylate (Glubran; GEM SRL, Viareggio, Italy).
bined with an endorectal advancement flap [169].
The glues are applied to fill the fistula track and provide
Various strategies have been suggested to improve
a bridge for fibroblasts and stromo-vascular cell in-
the healing rates with glues. Local sepsis should be
growth to produce healing. Their ease of use, minimal
eradicated with the use of preoperative setons, the track
risk to continence and repeatability make them an
should be thoroughly curetted and the track irrigated
attractive option, especially in patients at high risk of
with either saline or hydrogen peroxide. Preoperative
sphincter dysfunction [150,151].
bowel preparation has not consistently shown a benefit.
A wide range of healing rates with fibrin glues have
Suturing the internal or external openings shut has been
been reported, ranging from 14% to 94% [152,153].
advocated, but not shown to confer a significant benefit
Variability in disease complexity, fistula anatomy and
[152].
surgical technique makes comparison of the results from
It has been suggested that high failure rates with the
randomized trials difficult to interpret [154–156]. A
glue may be a consequence of the glue not being
meta-analysis has not shown any statistical difference
retained in the fistula track [170,171]. To overcome
with the use of fibrin glue, compared to other conven-
this, some authors have recommended the use of stool
tional surgical treatments, in terms of fistula recurrence
softeners and avoiding straining and exercise in the
or incontinence [157].
postoperative period, although there are no data to sup-
Some authors have reported better healing rates in
port this. Other explanations for failure of fibrin glue
longer tracks, suggesting that shorter tracks (< 3.5 cm)
include early resorption/degradation within 5–10 days
are less likely to retain the glue [155,158], but this has
of application, providing insufficient time for established
been contradicted in other reports [159–161]. Techni-
healing [165,171]. A Phase I trial using Permacol
cal errors have been suggested for failure, including
glue, which incorporates fibres suspended in fibrin glue
inadequate curettage and washout to remove all
to provide a physical scaffold for host cell proliferation
infected and epithelialized tissue [155,161,162], or
after glue absorption, has shown promising results, but
incomplete filling of the track with the glue to ensure
more, randomized, data are required [165]. Newer
occlusion [155].
autologous fibrin sealants have not shown any increased
Like other fistula treatments, recurrence rates with
efficacy compared with conventional glues, with healing
fibrin glue increase with the length of follow-up. A long-
rates of up to 40% [172]. Research continues into the
term follow-up study showed that up to 26% of patients
use of stem cell autologous suspensions for fistula appli-
who were symptom free at 6 months went on to develop
cation and the ADMIRE CD study used fibrin glue as
recurrence at an average of 4.1 years [163]. However,
the scaffold for allogeneic mesenchymal stem cell treat-
on several occasions the recurrence was at a different site,
ment of Crohn’s anal fistulas [173]. This may represent
suggesting that a new fistula had formed. The highest
the main role for fibrin glue in the future.
probability of failure appears to occur in the first
6 months following treatment, so 6 months should be
the minimum follow up period [152,161,164,165].
A multicentre trial randomized patients to fibrin glue Fistula plugs
or seton treatment for transsphincteric fistulas and Findings
showed a 38% healing rate in the fibrin glue group,
compared with 87% in the seton group [150]. Patients The initial reported high success rates of anal fistula
who had a recurrence after fibrin glue were further ran- plugs have not been maintained in later series, but,
domized to repeat glue treatment or a loose seton. A similar to fibrin glue, anal fistula plugs do not threaten
further 50% healed with repeat glue treatment. Notably, continence. It remains uncertain as to which fistulas
there was a significant worsening in the Cleveland Clinic are best suited to fistula plug treatment. (Level I)

Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31 17
The treatment of anal fistula (2018 update)
Recommendations
Accepting that rates of healing are variable, an anal fis-
tula plug is an option for treating transsphincteric fis-
tulas, especially where surgical options are considered
to have a significant risk of jeopardizing continence.
The additional cost of the plug should be taken into
account when considering this surgical treatment.
(Grade C)
Anal fistula plugs (AFPs) are bioprosthetic or syn-
thetic materials used to occlude the fistula track, block-
ing the internal opening and preventing faecal material
from entering. They provide a physical scaffold for in-
growth of host regenerative and immune cells to pro-
mote healing and repair. The plugs degrade over a per-
iod of several weeks, by which time the repair process is
established.
Types of plug. Several fistula plugs have been developed
commercially, but the BioDesign Surgisis Anal Fistula
Plug (Cook Medical, Bloomington, Indiana, USA),
composed of acellular, lyophilized porcine intestinal
submucosa, is the most established. Other plugs include
the GORE Bio A Fistula Plug (Flagstaff, Arizona,
USA), a composite of polyglycolic acid and
trimethylenecarbonate synthetic polymers [174], which
has now been withdrawn by the manufacturer, the
Pressfit plug (Deco Med s.r.l., Venice, Italy), which is
made from acellular dermal matrix, and the Curaseal
AF device (CuraSeal, Inc., Santa Clara, California,
USA), which incorporates a silicone disc to reinforce
occlusion of the internal fistula opening. Secure anchor-
ing of the plug at the internal opening is a critical fea-
ture in the design of all these plugs.
Surgical technique. Reported success rates for fistula
healing with plugs vary, ranging from 24% to 88%
[175], reflecting differences in patient selection, plugs
used, surgical technique, definition of healing and
length of follow-up. In 2007, a Consensus Conference
was held to establish uniformity in the indications and
techniques for insertion of the Cook Medical fistula
plug [176]. It concluded that all types of ano-cutaneous
fistula were suitable for plug treatment, with
transsphincteric fistulas being the ideal indication.
Emphasis was placed on the prior control of associated
sepsis and the use of seton drainage for 6–12 weeks
preoperatively. Debridement or curettage of the track
was discouraged, although gentle brushing to de-
epithelialize the track was subsequently recommended,
with saline or hydrogen peroxide irrigation being
optional. Secure suturing of the plug to the internal
opening/internal sphincter was considered important to
18 Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
G. Williams et al.
prevent early extrusion of the plug, which had been
reported as a cause for failure in some studies [177].
There was no evidence to support the routine use of a
rectal mucosal flap to cover the plug. Suturing of the
plug has been facilitated by modification of the original
plug design to incorporate an internal ‘button’.
Initial encouraging results from Johnson et al. [178]
reporting closure rates of up to 87% have not been repro-
duced in later studies, which have presented mixed
results. A randomized trial comparing the fistula plug
with endorectal advancement flap (ERAF) was closed
prematurely due to a high incidence of recurrence in the
plug arm [179]. In another RCT, comparing an acellular
dermal matrix (ADM) plug vs ERAF, a healing rate of
82% was reported in the ADM group, with lower rates of
recurrence (ADM plug 4% vs ERAF 28%) [180]. A sub-
sequent meta-analysis comparing the plug with ERAF
failed to show any difference in recurrence rates or com-
plications [181]. However, a recent robust multicentre
RCT of 94 patients with a transsphincteric fistula
demonstrated clinical healing at 12 months in only 38%
(15 of 44 patients) treated by collagen plug, compared
with 66% (27 of 41 patients) treated by ERAF [148].
A potential disadvantage with the plug is the cost of the
device, but this may be offset by a shorter hospital stay. In
a study comparing fistula plug against ERAF, healing rates
were similar, but the costs associated with ERAF were
higher due to a longer duration of hospital stay [182].
In a recent UK multicentre study (the NIHR FIAT
trial) 152 patients were randomized to receive the Cook
Biodesign fistula plug and compared with 152 patients
receiving surgeon’s preference [cutting seton, ERAF, fis-
tulotomy or ligation of intersphincteric fistula track
(LIFT)]. Similar clinical fistula healing rates were
observed at 12 months’ follow-up (plug 54% vs sur-
geon’s preference 57%). Early plug extrusion remained a
problem, despite the adoption of best surgical technique,
occurring in 15% of cases. Rates of incontinence were low
in both groups and there was no statistical difference in
quality of life as measured by the FIQoL and EQ-5D
scoring systems. Complications rates were similar
between the two groups, with the exception of increased
early postoperative pain in the plug group, presumably
associated with suturing to the internal anal sphincter.
The fistula plug has been successfully used in combi-
nation with other procedures, including the LIFT pro-
cedure. In a large, multicentre RCT, the LIFT–plug
procedure was found to result in statistically significant
higher healing rates compared with LIFT alone (LIFT–
plug 94.0% vs LIFT 83.9%; P < 0.001) [183].
Most studies have included variable follow-up after
surgery, ranging from 3 to 12 months. A long-term fol-
low-up study, using MRI to assess fistula healing at
G. Williams et al.
12 months after plug insertion, showed radiological evi-
dence of a persistent fistula in up to 21% of patients,
suggesting that reports of fistula healing at 12 months
are likely to be an overestimate [184].
Benefits in favour of the fistula plug include ease of
use and lack of complications. No differences in compli-
cation rates have been reported between ERAF and
AFP [181], with documented complications including
sepsis/abscess, recurrence and constipation
[183,185,186]. Unlike some other techniques, no study
has reported a detrimental effect to continence follow-
ing use of a plug. Thus, the fistula plug is an option for
treating a transsphincteric fistula. Uncertainty in healing
efficacy is counterweighed by the lack of detrimental
effect on continence. The cost of the device might be
offset by shorter lengths of hospital stay.
Novel techniques
Findings
A number of novel surgical techniques for anal fistulas
have been developed over the last 10 years. These
include the LIFT procedure, lasers, clips, video-
assisted anal fistula treatment (VAAFT) and autolo-
gous adipose-derived stem cells. Evidence of efficacy is
scant and largely confined to personal series (Level III
evidence) with a paucity of RCTs performed to date,
and what is available is confined to the LIFT proce-
dure. Whilst initial work on other techniques looks
interesting, with minimal adverse events reported,
long-term follow-up needs to be reported as many
institutional series only document short/medium fol-
low-up, functional outcome data are limited and few
patient-reported outcome data are available. A degree
of standardization is required in approaches using
multiple concurrent treatments. Randomized evidence
is needed before these new techniques will challenge
conventional approaches.
Recommendation:
The LIFT procedure is an option for treatment of a
transsphincteric fistula, with or without insertion of a bio-
prosthetic graft in the intersphincteric space. (Grade B)
It is too early to recommend the routine use of other
novel treatments for anal fistula. (Grade C)
The LIFT procedure. The LIFT procedure was first
reported in 2007 [187], when healing was seen in 17
of the first 18 patients reported. The principle is essen-
tially to make an incision in the intersphincteric groove,
Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
The treatment of anal fistula (2018 update)
ligate the intersphincteric fistula track, remove the fis-
tula track and then curette it from the external opening.
The external sphincter muscle defect is closed, as is the
intersphincteric wound.
Three RCTs have been reported [183,188,189]
(Table 2). One only compared LIFT with a modifica-
tion of LIFT, rather than a standard treatment, whilst
the other two compared LIFT with a mucosal advance-
ment flap. In addition, 18 case series have been
reviewed [187,190–206] (Table 3). A number of series
reporting fewer than 10 patients were disregarded for
the purposes of this position statement.
Madbouly et al. [189] randomized 70 patients to
either LIFT or a mucosal advancement flap. Primary
healing was achieved in 33 (94%) patients undergoing
LIFT compared with 32 (91%) patients undergoing a
flap repair. Median healing times were 22.6 and
32.1 days, respectively. After follow-up of 1 year, a suc-
cessful outcome was achieved in 26 (74%) of the LIFT
group compared with 20 (66%) in the advancement flap
group (P = 0.58), highlighting the importance of long-
term follow up in fistula surgery research. There was no
significant difference in continence scores in this study.
A similar, but smaller, study randomized 25 patients
to LIFT and 14 to anorectal advancement flap [188].
All patients had seton inserted prior to definitive sur-
gery. Recurrences were seen in 2/25 and 1/14, respec-
tively. The authors concluded that LIFT was simple and
safe, took significantly less time than a flap and patients
returned to work earlier.
Sileri et al. [194] reported 26 patients with complex
fistulas, 19 of whom were healed at a minimum of
16 months following LIFT. The recurrences occurred
between 4 and 8 weeks following surgery. They defined
‘complex’ as any track that was deeper than 30% of the
external sphincter, anterior fistula in women, recurrent
fistula or preexisting incontinence. Only two patients
had previously had a loose seton inserted prior to the
LIFT procedure. Another series of 40 patients with
transsphincteric fistulas deemed to be inappropriate for
fistulotomy underwent LIFT [205]. Success rates of up
to 74% were noted, although follow-up was short (a
mean of 18 weeks).
Ooi et al. [199] reported 25 patients who had
undergone LIFT. Ten of them had developed recur-
rence after previous fistula surgery. The primary and
secondary end-points were cure rate and degree of
incontinence, respectively. Primary healing was observed
in 17 (68%) patients at a median of 6 weeks. Seven
patients had recurrence of their fistula, which presented
between 7 and 20 weeks’ postoperatively. There was no
reported incontinence. Liu et al. [204] recruited 38
patients between 2008 and 2011. At a median follow-
19
The treatment of anal fistula (2018 update)
Table 2 Randomized controlled trials of ligation of intersphincteric fistula track (LIFT; Level I evidence).
Authors Trial design Numbers
Han et al. LIFT vs LIFT plug 235
(2016) [183]
Madbouly LIFT vs mucosal 70
et al. (2014) advancement flap
[189]
Mushaya LIFT vs anorectal LIFT 25
et al. (2012) advancement flap Flap 14
[188]
up of 26 months (26 patients had at least 12 months’
follow-up), healing was seen in 23/38 (61%). One fail-
ure occurred over 12 months after the index procedure,
with 80% of failures occurring within the first 6 months
following the procedure. No intra-operative complica-
tions or incontinence were noted. Increasing fistula
length was associated with decreased likelihood of heal-
ing.
A recent large series (167 patients) reported a success
rate (healing) of 94% at a median follow-up of
12 months [198]. The majority of fistulas were
transsphincteric [150], and a number were recurrent
[33]. Ten patients who developed a recurrent fistula were
managed with a repeat LIFT procedure. Schulze et al.
[196] performed LIFT on 75 patients between May
2008 and June 2013. All had undergone an initial proce-
dure that involved drainage of sepsis, insertion of a loose
seton and partial fistulotomy. There were nine recur-
rences, at a mean follow-up of 14.6 months, all of which
were treated with repeat LIFT and biograft or anorectal
advancement flap. There were no subsequent recur-
rences. Recurrences were related to fistulas with multiple
tracks. Only one patient reported a change in continence.
An attempt has been made to determine whether
LIFT is more effective in distinct fistula sub-types [197].
LIFT was performed in simple transsphincteric (five),
complex fistulae (six) and recurrent cases postfistulotomy
(six). The overall success rate at a mean follow-up of
11 months was 53%. Healing rates in the three groups
were four out of five, three out of six and two out of six,
respectively. These numbers are too small to draw any
conclusions, but intuitively LIFT should be more likely
to succeed in less complicated fistulas (as is the case for
all fistula treatments). There is general consensus that
the presence of multiple tracks, diabetes mellitus, peri-
anal collections and long tracks are all associated with a
higher chance of failure of LIFT.
LIFT has been employed as an alternative to fistulo-
tomy in patients with low transsphincteric fistulas
20 Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
G. Williams et al.
Median
Healing rates follow up Incontinence
LIFT–plug 94.0% 6 months None
LIFT 83.9%
LIFT 26/35 12 months No change in Wexner
Mucosal advancement score at 4 weeks
flap 20/35 (P = 0.58)
Recurrences of 2/25 in 19 months One flap patient noted to
LIFT vs 1/14 in flap have minor incontinence
[190]. Healing was seen in 18/22 patients recruited at
a median follow-up of 19.5 months. The four unsuc-
cessful cases were treated with fistulotomy. Although
there was no comparison with patients with similar fis-
tulas undergoing fistulotomy as sole treatment, the
authors reported a final healing rate of 100% and no
alteration in continence, which was assessed prospec-
tively.
A Chinese group recently reported on 43 patients
with ‘complex’ fistulas treated by LIFT, all of whom
were followed up for more than 1 year [201]. Healing
of the fistula was seen in 36 of 43 (84%) patients; fail-
ure, when seen, occurred a mean of 8.6 weeks after the
original procedure. In this series, eight patients had
dehiscence or infection at the site of the intersphincteric
wound, with five patients requiring laying open. This
complication is probably commoner than reported in
many series.
Modifications to the LIFT procedure have been
described. The Bio-LIFT procedure, for example,
involves placing a biograft (usually a piece of collagen
mesh) in the intersphincteric space following ligation of
the intersphincteric fistula track. Success was reported in
11 of 16 (63%) fistulas treated, at a median follow-up
of 26 weeks [192]. A randomized trial comparing the
two approaches in 235 patients reported healing rates at
6 months of 94% in the LIFT + biograft group, vs 84%
in the LIFT group alone [183]. The authors reported
that the addition of the graft had the advantage of
higher healing rates, decreased healing time and a lower
early postoperative pain score. Another modification
involves making a lateral incision from the external
opening to the intersphincteric groove, ligating the fis-
tula track within the intersphincteric space and complete
excision of the external part of the fistula [195]. In a
series of 39 patients treated in this way and followed for
a mean of 15 months, 34 (87%) achieved healing.
There was no change in continence, as measured by the
Cleveland Clinic score preoperatively and at 6 months
 Table 3 Case series of ligation of intersphincteric fistula track (LIFT; Level III evidence).

Author Number Types of fistula Healing rates Follow-up Comments

G. Williams et al.

Parthasarathi 167 150 transsphincteric 94% Median 12 months Seven patients underwent repeat LIFT
et al. (2016) [198] 16 intersphincteric (range 4–22) procedure
1 suprasphincteric Recurrence associated with diabetes
(33 recurrent) mellitus and perianal collections
Chen et al. 43 Uncomplicated transsphincteric 36/43 (84%) ≥ 12 months – median Eight had dehiscence or infection at the
(2016) [201] (29), horseshoe transsphincteric follow-up of wound site – five of these required
(10) and multiple fistulas (4) 26.2 months laying open procedures
Bastawrous et al. 66 procedures Transsphincteric 71% Median 21 weeks Modified LIFT – intersphincteric
(2015) [202] in 56 patients component de-roofed
Romaniszyn et al. 17 Transsphincteric, complex 8/17 (47%) Mean 11 months Best results seen in simple fistulas
(2015) [197] and recurrent
Schulze et al. 75 ‘Complex’ cryptogenic 66/75 (88%) Mean of 14.6 months LIFT following seton placement and
(2015) [196] Nine recurrences partial fistulotomy
diagnosed at a mean of One patient developed minor incontinence
9.2 months
Ye et al. (2015) 43 High transsphincteric 34/39 (87%, four lost to Mean of 15 months Modified LIFT
[195] follow up)
Sileri et al. 26 ‘Complex’ fistula 19/26 (73%) ≥ 16 months Complex defined as track crossing > 30%
(2014) [194] of external sphincter, anterior fistula in a
woman, recurrent fistula and preexisting
incontinence
Tan et al. (2014) [192] 13 patients Transsphincteric 11 healed Median of 26 weeks Four patients had a previous failed LIFT
with 16 fistulas BioLIFT was performed with insertion
of a bioprosthetic graft in the
intersphincteric space
Gingold et al. 15 Transsphincteric 9/12 (75%) at 2 months All had Crohn’s disease

Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
≥ 12 months
(2014) [200] 8/12 (66%) at 12 months
Campbell et al. 20 Consecutive patients 14/20 (70%) at 1 month 18 months
(2013) [193] 16/20 (80%) at 3 months
Liu et al. (2013) 38 Transsphincteric 23/38 (61%) 26 months (range 3–44) Increased length of track associated with
[204] poorer healing
Van Onkelen et al. 22 Low transsphincteric 18/22 (82%) Median 19.5 months
(2013) [190]
Lehmann et al. (2013) 17 Recurrent transsphincteric 9/15 (60%) Median 13.5 months
[191]
The treatment of anal fistula (2018 update)

21
The treatment of anal fistula (2018 update) G. Williams et al.

postoperatively. An alternative approach is to de-roof

All fistulas were deemed unsuitable for

the fistula from internal opening to intersphincteric
groove and ligate the fistula track, while at the same
time preserving the external sphincter. This modified

No evidence of postoperative
LIFT was performed on a series 56 patients, with an
overall cure rate of 71%. True recurrence (5%) was
much less frequent than simple failure of the technique

No morbidity noted
and persistence of an active fistula track after the opera-
tion [202].
incontinence
laying open
Comments

LIFT has been used as treatment for recurrent fistu-

las [191]. Fifteen patients with recurrent transsphinc-
teric fistulas were followed up for 8–26 months
(median 13.5 months). At the end of follow-up, six
patients still had evidence of fistula, either persistence of
Median of 5 months

the original fistula (four patients) or recurrence (two

Mean healing time
Median 9 months
Median 22 weeks

patients). LIFT has also been used in selected patients

with Crohn’s disease, with 8 of 12 reported to be
was 4 weeks

healed at 12 months [200].

Follow-up

18 weeks

To conclude, to date there are a few randomized

studies as well as number of case series that attest to the
potential efficacy of LIFT. LIFT appears to be associ-
ated with less functional compromise than some tradi-
tional treatments of transsphincteric fistulas, although
recurrence/persistence rates are probably similar. One
in 17/25 (68%)

in 37/45 (82%)
Primary healing

Primary healing

of the advantages of the LIFT procedure is that of sec-

22/39 (56%)

17/18 (94%)
Healing rates

ondary success. Where a genuine downstaging of the

fistula from transsphincteric to intersphincteric takes
74–90%

place in a proportion of failures, allowing laying open of

this intersphincteric fistula, preserving the external
sphincter which would have been involved originally
[207]. Future work should focus on comparison with
Trans- and suprasphincteric
Unselected transsphincteric

standard treatments, paying particular attention to com-

Transsphincteric (n = 33)

(five recurrent fistulas)

paring similar fistulas and focusing on deeper fistulas,

Complex (n = 12)

where conventional treatments may be more problem-

Cryptoglandular

Transsphincteric

atic as regards functional outcome.

Types of fistula

Stem cell therapy. Autologous adipose-derived stem cells

may represent a novel treatment option for complex fis-
tulas, although as yet there is insufficient evidence to
attest to its efficacy. As a technique it may be used in
40 (41 procedures)

25 (10 recurrent)

isolation or in combination with fibrin glue or advance-

ment flaps. It has been used in patients with Crohn’s
disease. Allogeneic, expanded, adipose-derived stem
Number

cells have been used in a randomized, multicentre, dou-

ble-blind placebo-controlled study involving 212
39

45

18

patients [173]. The primary end-point was remission at

24 weeks. In the intention-to-treat analysis 53/107
Table 3 (Continued).

(50%) receiving stem cells achieved this, compared with

Rojanasakul et al.
Ooi et al. (2012)

36/105 (34%) in the placebo arm (P = 0.024). A sepa-

Shanwani et al.
(2012) [205]

(2010) [203]

(2010) [206]

(2007) [187]
Abcarian et al.

rate multicentre, single-blind trial randomized 200

Bleier et al.

patients to stem cells alone, stem cells in combination

Author

[199]

with fibrin glue or fibrin glue alone, following closure

of the internal opening [208]. There was no significant

22 Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
G. Williams et al.
difference in healing rates between any of the groups,
which were 40–50% at 12 months’ follow-up: no seri-
ous adverse events were reported. A further small case
series of seven patients reported healing rates of five out
of seven at 6 months and four out of seven at a median
of 46 months [209]. Long-term results of a Phase II
trial in patients with Crohn’s disease reported healing
rates of 75% at 24 months’ follow-up [210]. Recently
reported work looked at whether autologous mesenchy-
mal stem cells could heal fistulas in Crohn’s disease if
applied in a bioabsorbable matrix [211]. At 6 months
10/12 patients had complete clinical healing. It is too
soon to comment on the role of this complex treatment
in the routine management of anal fistulas.
Laser therapy. Laser therapy was described as a treat-
ment option for anal fistula in the 1980s [212], and
more recently with a radial emitting laser probe [213],
the principle being to destroy epithelial cells lining the
fistula track. It has been trialled in combination with
fibrin glue [214], although more recent work, using the
laser in isolation, demonstrated healing in 9 of 11
patients at a median of 7.4 months [213]. In this study,
the internal opening was closed using a flap in combina-
tion with laser ablation. A further larger study, recruit-
ing 45 patients, found healing in 32 (71%) at a median
of 30 months [215]. All patients underwent placement
of a loose seton prior to surgery, and 35 patients had a
history of previous fistula surgery. A retrospective review
of 50 patients treated by laser ablation showed ‘success’
in 41 (82%) at 12 months’ follow-up [216], which was
mostly by phone, consequently these results need inter-
preting with caution. Wilhelm et al. [217] reported a
series of 117 patients treated with the radial fibre fistula
laser closing (FiLaCTM) device. Patients in this series
were followed for a median of 25 months (minimum
6 months) with primary healing in 64% of patients. A
repeat procedure was performed in 31 patients who
failed initial treatment, with overall healing achieved in
88% of patients. The treatment was associated with min-
imal alteration in anal control.
At present, laser ablation of a fistula track is in its
infancy, with evidence supporting its use confined to
a few case series (Level II/III evidence). The best
technique has not been established: for instance, is
surgical closure of the internal opening necessary prior
to laser ablation? Further larger studies, especially ran-
domized trails against other sphincter-preserving tech-
niques, are required to establish its role in treatment
of anal fistulas.
Fistula clips. The principle of this technique is to deb-
ride the primary track and close the internal opening
Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
The treatment of anal fistula (2018 update)
with a tightly applied metal clip. The most extensively
investigated apparatus is the OTSC Proctology
(Ovesco Endoscopy AG, Tu72074 T€ ubingen, Ger-
many), which employs a nitinol clip. A recent case-series
has demonstrated healing in 18 of 20 (90%) fistulas at
6 months [218]. This group consisted of 14 patients
with a transsphincteric fistula and 6 with suprasphinc-
teric fistulas, although details of the complexity of the
tracks was not given. Two patients required removal of
the clip as a result of delayed wound healing and dis-
comfort. Another case-series of consecutive patients
from a single institution used the OTSC in refractory
cases of anal fistula following previous surgery [219].
Six of the 10 patients recruited had Crohn’s disease.
Seven patients’ fistulas were healed at a median follow-
up of approximately 8 months. The FISCLOSE trial is
aimed at evaluating the efficacy and safety of a clip vs
rectal mucosal advancement flap [220]. The aim is to
recruit 46 patients to two centres. The primary out-
come is healing at 3 months. Secondary outcomes
include healing at 6 and 12 months, anal pain, faecal
incontinence and quality of life.
In a similar way to laser ablation, clipping the inter-
nal opening of a fistula is at an early stage of evolution,
with a few encouraging case series having been pub-
lished (Level II/III evidence). Migration and pain,
requiring removal of the clip at the request of patient,
are significant risks that have been reported in the few
studies which have been reported. Further larger stud-
ies, especially randomized trails against other sphincter-
preserving techniques, are required to establish whether
it has role in treatment of anal fistulas.
Video-assisted anal fistula treatment. Video-assisted anal
fistula treatment (VAAFT) consists of a diagnostic and a
therapeutic phase. In the former, a fistuloscope and
obturator are used to identify the internal opening as
well as any secondary tracks and/or abscesses. The
scope is inserted through the external opening and a
glycine-mannitol solution infused to enable opening of
the primary track and advancement under direct vision.
The therapeutic phase involves destruction and cleaning
of the track using cautery and further irrigation. One of
the principles is closure of the internal opening using a
circular/linear stapler, OTSC or advancement/mucosal
flap. Cyanoacrylate may be used to reinforce the closure
of the internal opening, though the track must be left
open to allow secretions to drain.
Work from Italy reported on 136 patients undergoing
VAAFT over a 5-year period [221]. Ninety-eight patients
were followed up for a minimum of 6 months. Primary
healing occurred in 72 (73%) patients within 2–
3 months of surgery, with no major complications seen.
23
The treatment of anal fistula (2018 update)
Sixty-two patients were followed up for over a year, with
healing noted in 52 (84%). A further study from Singa-
pore reported on 41 patients treated with VAAFT [222]:
all were cryptoglandular in aetiology, though low inter-
sphincteric fistulas and patients with abscesses were
excluded. A number of approaches were used to obliter-
ate the internal opening – stapling, advancement flap and
OTSC. Eleven patients had undergone previous fistula
surgery. Overall primary healing was seen in 29 (71%)
patients at a median follow-up of 34 months, with the
best results seen with VAAFT in combination with the
OTSC. This approach has also been used in patients with
Crohn’s disease in combination with an advancement
flap [223]. Success in the 13 patients recruited was
defined as closure of both internal and external openings,
absence of drainage without requirement for interven-
tion and no abscess formation. All patients had complex
fistulae, five were on biological agents and four had a
proximal stoma. At a mean follow-up of 9 months 9 of
11 patients, where VAAFT was technically possible, were
deemed a success, and no deterioration in continence
was observed. VAAFT has also been reported in a paedi-
atric population [224]. Thirteen procedures were per-
formed on nine children (mean age 9.6 years). One was
associated with Crohn’s disease, though only five were
described as idiopathic. All patients who underwent a
complete VAAFT (n = 8) were healed at 10 months.
VAAFT is another novel treatment that shows some
promise, although it is far from clear which part of the
treatment is important and whether the video element
is vital to its success or whether thorough cleaning of
the track and secure closure of the internal opening is
equally successful, saving the investment in the video
technology. Proponents argue that the diagnostic phase
finds tracks that MRI has missed, although evidence to
support this assertion is lacking. More detailed studies
are required before this dilemma can be resolved and
the role of VAAFT be defined.
Conclusions
Anal fistula continues to perplex surgeons, and in the
10 years since the first version of this Position State-
ment was published, a number of new treatments have
been developed. Although many of these treatments
show promise, it is too early to state whether they are
superior to well-tried surgical treatments for anal fistula,
which should continue to be the ‘gold-standard’ against
which newer treatments are compared. Drawing conclu-
sions for the literature remains difficult because the
quality of publications is variable, with many studies
having limited follow-up or poor definitions of end-
points. However, randomized trials are becoming more
24 Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain and Ireland. 20 (Suppl. 3), 5–31
G. Williams et al.
common and are to be welcomed. As well as focusing
on surgical end-points (healing, alteration in anal con-
trol, etc.) future trials should also include data on
patient-reported outcome measures.
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